TEMPLATE Radiologischer Befund - Cholangiokarzinom (Radiologischer Befund - Cholangiokarzinom)

TEMPLATE IDRadiologischer Befund - Cholangiokarzinom
ConceptRadiologischer Befund - Cholangiokarzinom
DescriptionZur Repräsentation der Ergebnisse und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen im Rahmen des HiGHmed-Projektes.
UseWird verwendet, um radiologische Befunde von CT und MRT bei Patienten mit Pankreaskarzinom zu berichten.
MisuseNicht zur Repräsentation der klinischen Veränderungen einer Krankheit verwenden.
PurposeZur Repräsentation der Ergebnisse und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen im Rahmen des HiGHmed-Projektes.
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=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=641B268BE8805CEB8DC21AB82C53AB3F, original_language=ISO_639-1::de, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=9fe3b79c66bd2d4f2cb97d56434c41c4, build_uid=0c80c276-ecf5-4634-8c81-20008f20ecd3, sem_ver=11.0.1}
KeywordsRadiologischer Befund; Report; Pankreaskarzinom; HiGHmed; UseCase Onkologie; Tumorbildgebung; Tumor-Radiologische Diagnose; Bildgebung; Diagnostik; Bildgebendes Verfahren; Bildgebende Diagnostik; CT; MRT
Language useden
Citeable Identifier1246.169.1936
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=Aurelie Tomczak, Institute of Pathology, University Hospital Heidelberg; Nina Bougatf, University Hospital Heidelberg; Natalia Strauch, Medizinische Hochschule Hannover; Antje Wulff, Medizinische Hochschule Hannover, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Radiologischer Befund - Cholangiokarzinom, 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[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Vorläufig
  • Final
  • Korrigiert
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  • Abdomen - Untersuchung der Gallenwege
Default value: Abdomen - Untersuchung der Gallenwege, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Modality, description=Type of equipment that originally acquired the image or series of images., comment=Also known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the 'Test name', then this field may be redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • CT
  • MR
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Zeitpunkt der Bildgebung, description=The date and/or time that the result was issued for the recorded 'Examination result status'., 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0061], code=at0061, itemType=ELEMENT, level=5, text=Behandlungssituation, description=Narrative description about the reason for requesting the examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Initialbefund
  • Nach Neoadjuvanz
  • Nach lokaler Therapie
  • Unter systemischer Therapie
  • Verlaufskontrolle ohne Therapie
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Befundtext, description=Narrative description of the clinical findings., 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor'], code=at0000, itemType=CLUSTER, level=5, text=Primärtumor, description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Primärtumor
Default value: Primärtumor, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=6, text=Tumorlokalisation, description=A physical site on or within the human body., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Tumorlokalisation, 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=
  • Intrahepatisch
  • perihilär
  • distal
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=7, text=Lebersegment bei intrahepatisch, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. 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=
  • nicht anwendbar
  • Lebersegment 1
  • Lebersegment 2
  • Lebersegment 3
  • Lebersegment 4
  • Lebersegment 4a
  • Lebersegment 4b
  • Lebersegment 4a/b
  • Lebersegment 5
  • Lebersegment 6
  • Lebersegment 7
  • Lebersegment 8
  • Lebersegmente 2/3
  • Lebersegmente 7/6
  • Lebersegmente 8/5
  • Lebersegmente 2/4a
  • Lebersegmente 3/4b
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=7, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Primärtumor vorhanden?, description=The presence or absence of the finding., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt TC (truncus coeliacus)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt TC (truncus coeliacus), description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt TC (truncus coeliacus)']/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt TC (truncus coeliacus)
Default value: Gefäßkontakt TC (truncus coeliacus), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt TC (truncus coeliacus)']/items[at0028], code=at0028, itemType=ELEMENT, level=7, text=Gefäßkontakt TC (truncus coeliacus), description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Kein Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt TC (truncus coeliacus)']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt TC, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt LA (Leberarterie)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt LA (Leberarterie), description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt LA (Leberarterie)']/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt LA (Leberarterie)
Default value: Gefäßkontakt LA (Leberarterie), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt LA (Leberarterie)']/items[at0028], code=at0028, itemType=ELEMENT, level=7, text=Gefäßkontakt LA (Leberarterie), description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Kein Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt LA (Leberarterie)']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt LA, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt AMS (Arteria mesenterica superior), description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)']/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt AMS (Arteria mesenterica superior)
Default value: Gefäßkontakt AMS (Arteria mesenterica superior), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)']/items[at0028], code=at0028, itemType=ELEMENT, level=7, text=Gefäßkontakt AMS (Arteria mesenterica superior), description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Kein Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt AMS, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt VMS (Vena mesenterica superia), description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)']/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt VMS (Vena mesenterica superia)
Default value: Gefäßkontakt VMS (Vena mesenterica superia), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)']/items[at0028], code=at0028, itemType=ELEMENT, level=7, text=Gefäßkontakt VMS (Vena mesenterica superia), description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Kein Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt VMS, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt PA (inkl. PA-Thrombose), description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)']/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt PA (inkl. PA-Thrombose)
Default value: Gefäßkontakt PA (inkl. PA-Thrombose), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)']/items[at0028], code=at0028, itemType=ELEMENT, level=7, text=Gefäßkontakt PA (inkl. PA-Thrombose), description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Kein Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt PA, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Primärtumor']/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Kommentar zum Primärtumor, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Pfortaderthrombose'], code=at0000, itemType=CLUSTER, level=5, text=Pfortaderthrombose, description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Pfortaderthrombose']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Pfortaderthrombose
Default value: Pfortaderthrombose, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Pfortaderthrombose']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Presence?, description=The presence or absence of the finding., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Pfortaderthrombose']/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Pfortaderthrombose Kommentar, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1], code=at0000, itemType=CLUSTER, level=5, text=Beurteilung des Therapieansprechens (RECIST 1.1), description=Bewertung des Ansprechens einer Erkrankung auf die Therapie. Dies hilft dabei, den Erfolg der Behandlung, z.B. einer Strahlen- oder Chemotherapie bei einer Tumorerkrankung zu beurteilen., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=RECIST 1.1, description=Ausdruck, der das Ansprechen auf die Behandlung einer Erkrankung beschreibt., comment=Es handelt sich um eine bereits kodierte Terminologie des Ansprechens auf z.B. eine onkologische Therapie. Ausprägungen können beispielsweise CR (Vollremisson der Erkrankung), PR (Teilremission), SD (Stabile Erkrankung) oder PD (Progression der Erkrankung) sein., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • PR (partial response) 
  • SD (stable disease) 
  • PD (progressive disease) 
  • CR (complete response) 
  • U (Beurteilung unmöglich) 
  • X (Fehlende Angabe) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Lokalrezediv'], code=at0000, itemType=CLUSTER, level=5, text=Lokalrezediv, description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Lokalrezediv']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Lokalrezediv
Default value: Lokalrezediv, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Lokalrezediv']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Presence?, description=The presence or absence of the finding., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Lokalrezediv']/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Lokalrezediv Kommentar, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Fernmetastasen'], code=at0000, itemType=CLUSTER, level=5, text=Fernmetastasen, description=A single finding in an imaging examination., 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Fernmetastasen']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Finding name, description=The name of the finding., comment=Coding with an external terminology is strongly recommended., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Fernmetastasen
Default value: Fernmetastasen, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Fernmetastasen']/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=6, 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Fernmetastasen']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, 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
  • KID
  • SKI
  • OTH
  • NULL
  • GEN
  • [...]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Fernmetastasen']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Presence?, description=The presence or absence of the finding., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0 and name/value='Fernmetastasen']/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Fernmetastasen Kommentar, description=Additional narrative about the finding, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=5, text=Verlaufsbeurteilung Gesamtbefund, description=Narrative description about the comparison of this examination, with previous similar studies., comment=Also use this data element to indicate if no comparison images and/or reports are available., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Befundkonstanz
  • Befundverbesserung
  • Befundverschlechterung
  • Divergentes Verhalten
  • Beurteilung ist nicht möglich
  • Nicht zutreffend (Initialbefund)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0063], code=at0063, itemType=ELEMENT, level=5, text=Diagnostische Qualität, description=Assessment about the quality of the examination., comment=Coding of the imaging quality with a value set is recommended. For example: 'excellent, good, fair, poor, and non-diagnostic'; or 'adequate, suboptimal and inadequate'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Qualität ausreichend
  • Qualität eingeschränkt
  • nicht diagnostisch
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Conclusion, description=Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate., comment=Also referred to as 'Opinion' or 'Impression'., 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-OBSERVATION.imaging_exam_result.v0]/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]/protocol[at0025]/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Maßnahmen-ID, description=The local identifier assigned to the examination order by the order filler, usually by the receiving Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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]/protocol[at0025]/items[at0036], code=at0036, itemType=ELEMENT, level=3, text=DICOM Studienkennzeichen, description=Unique identifier of the reported study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='Kontrastmittel'], code=at0000, itemType=CLUSTER, level=3, text=Kontrastmittel, description=Zur Darstellung der technischen Spezifikationen einer durchgeführten bildgebenden Untersuchung., 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]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='Kontrastmittel']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Bezeichnung des technischen Verfahrens, description=Zur Dokumentation des Typs des durchgeführten bildgebenden Verfahrens., comment=z. B. Diffusionswichtung bei MRT, die Art oder Weg der Verabreichung von Kontrastmittel, Radiopharmazeutika und / oder angewendete Behandlung., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Kontrastmittel
Default value: Kontrastmittel, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='Kontrastmittel']/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=KM Angewendete Parameter, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • nativ
  • extrazelluläres KM
  • intrazelluläres KM
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  • CT
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Native Phase'], code=at0014, itemType=ELEMENT, level=4, text=Native Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Native Phase - Ja
  • Native Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Spätarterielle Phase'], code=at0014, itemType=ELEMENT, level=4, text=Spätarterielle Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Spätarterielle Phase - Ja
  • Spätarterielle Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Venöse Phase'], code=at0014, itemType=ELEMENT, level=4, text=Venöse Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Venöse Phase - Ja
  • Venöse Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Spätvenöse Phase'], code=at0014, itemType=ELEMENT, level=4, text=Spätvenöse Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Spätvenöse Phase - Ja
  • Spätvenöse Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren'], code=at0000, itemType=CLUSTER, level=3, text=MR Verfahren, description=Zur Darstellung der technischen Spezifikationen einer durchgeführten bildgebenden Untersuchung., 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]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Bezeichnung des technischen Verfahrens, description=Zur Dokumentation des Typs des durchgeführten bildgebenden Verfahrens., comment=z. B. Diffusionswichtung bei MRT, die Art oder Weg der Verabreichung von Kontrastmittel, Radiopharmazeutika und / oder angewendete Behandlung., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • MR
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial - Ja
  • T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert nativ axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert nativ axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert nativ axial - Ja
  • T1 GRE fettsupprimiert nativ axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert spätarteriell axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert spätarteriell axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert spätarteriell axial - Ja
  • T1 GRE fettsupprimiert spätarteriell axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert venös axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert venös axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert venös axial - Ja
  • T1 GRE fettsupprimiert venös axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert spätvenös axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert spätvenös axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert spätvenös axial - Ja
  • T1 GRE fettsupprimiert spätvenös axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert hepatobiliär axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert hepatobiliär axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert hepatobiliär axial - Ja
  • T1 GRE fettsupprimiert hepatobiliär axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T2 axial'], code=at0014, itemType=ELEMENT, level=4, text=T2 axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T2 axial - Ja
  • T2 axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T2 koronar'], code=at0014, itemType=ELEMENT, level=4, text=T2 koronar, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T2 koronar - Ja
  • T2 koronar - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='Diffusionswichtung b=0-100 s/mm2'], code=at0014, itemType=ELEMENT, level=4, text=Diffusionswichtung b=0-100 s/mm2, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Diffusionswichtung b=0-100 s/mm2 - Ja
  • Diffusionswichtung b=0-100 s/mm2 - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='Diffusionswichtung b=500-1000 s/mm2'], code=at0014, itemType=ELEMENT, level=4, text=Diffusionswichtung b=500-1000 s/mm2, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Diffusionswichtung b=500-1000 s/mm2 - Ja
  • Diffusionswichtung b=500-1000 s/mm2 - Nein
, 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=Framework for consistent modelling of content within a template for a Problem list., comment=Intended to be used within the COMPOSITION.problem_list., 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], 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]/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]/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]/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]/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)
  • 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]/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]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0], code=at0000, itemType=CLUSTER, level=4, text=Tumor ID, description=Zur Darstellung der ID des Tumors., 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]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Tumor ID, description=Die ID/Kennung des Tumors., 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]], templateType=normal]