TEMPLATE Histopathologischer Befund_alternativ (Histopathologischer Befund_alternativ)

Name: Histopathologischer Befund_alternativ
License: http://creativecommons.org/licenses/by-sa/4.0/

TEMPLATE ID	Histopathologischer Befund_alternativ
Concept	Histopathologischer Befund_alternativ
Description	Das Template dient zur Erfassung der pathologisch-anatomischen Begutachtung mit kritischer Stellungnahme.
Use	Zur Repräsentation der pathologisch-anatomischen Begutachtung mit kritischer Stellungnahme.
Misuse	Nicht zur Repräsentation anderer pathologischer Befunde bestimmt.
Purpose	Das Template dient zur Erfassung der pathologisch-anatomischen Begutachtung mit kritischer Stellungnahme.
References
Authors	date: 2019-06-26; name: Aurelie Tomczak; organisation: Institute of Pathology, University Hospital Heidelberg; email: au.tomczak@yahoo.com
Other Details Language	date: 2019-06-26; name: Aurelie Tomczak; organisation: Institute of Pathology, University Hospital Heidelberg; email: au.tomczak@yahoo.com
Other Details (Language Independent)	Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/. Custodian Organisation: HiGHmed Original Namespace: org.openehr Original Publisher: openEHR Foundation Custodian Namespace: org.highmed MD5-CAM-1.0.1: 31b87dc2aee97c11f9d97b3525337f27 PARENT:MD5-CAM-1.0.1: 55DB2D45BC470E831EE8C905348471E4 Build Uid: 884ff6bd-ce65-4268-a9f2-6731eca57c5f
Keywords	Report; Befund; Histologie; Histopathologie; Pathologie; pTNM; Grading
Language used	en
Citeable Identifier	1246.169.231
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Histopathologischer Befund_alternativ	Histopathologischer Befund_alternativ: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Befund ID	Befund ID: Identification information about the report.
Status	Status: The status of the entire report. Note: This is not the status of any of the report components.
Histopathologischer Bericht	Histopathologischer Bericht: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Default value: Pathologisch-anatomische Begutachtung mit kritischer Stellungnahme
Overall test status	Overall test status: The status of the laboratory test result as a whole. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements. Coded Text Registered Partial Preliminary Final Amended Corrected Appended Cancelled Entered in error Text
Ausgangsdatum des Befund (Histologiedatum)	Ausgangsdatum des Befund (Histologiedatum): The date and/or time that ‘Overall test status’ was issued.
Diagnostic service category	Diagnostic service category: The diagnostic service or discipline that is responsible for the laboratory test result. This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.
Clinical information provided	Clinical information provided: Description of clinical information available at the time of interpretation of results. This data element may include a link to the original clinical information provided in the test request.
Anatomical pathology examination	Anatomical pathology examination: Findings and interpretation of an anatomical pathology examination performed on tissues and body fluids.
Examination type	Examination type: Identification of the type of anatomical pathology examination performed. Coded Text Macroscopic examination Microscopic examination Text
Anatomical pathology finding	Anatomical pathology finding: Details of an individual anatomical pathology finding, often related to a specific anatomical location or specimen.
Finding label	Finding label: A text label for the specific finding.
Finding description	Finding description: A narrative description of the anatomical pathology finding.
Surgical resection margins	Surgical resection margins: Details of tumour involvement at margins of surgical resections/biopsies.
Margin name	Margin name: The name of the margin being described. For example: 'closest margin', 'circumferential margin', 'deep margin', 'vascular margin' or 'bronchial margin'.
Marginal involvement	Marginal involvement: Evidence of tumour at a surgical resection margin. Present Absent Equivocal Indeterminate
Tumour present	Tumour present: Details where tumour is present at the surgical resection margin.
Maximum linear involvement	Maximum linear involvement: When tumour is present at surgical resection margin, the maximal length of involvement. >=0 mm
Nature of involvement	Nature of involvement: The nature of involvement of the tumour with the surgical margin.
Tumour absent	Tumour absent: Details where tumour is absent from surgical resection margins.
Distance from resection margin	Distance from resection margin: When tumour is absent, the distance from tumour to the named surgical resection margin. >=0 mm
Tumour name	Tumour name: Name of the tumour for which the 'Distance from resection margin' applies. For example: 'Invasive tumour' or 'Cancer in situ'.
Description	Description: A text description of tumour involvement at the surgical resection margin.
Lymph node metastases	Lymph node metastases: To record findings of tumour metastases in lymph nodes.
Lymph node site name	Lymph node site name: The name for the lymph node site being reported. This may be a general location e.g. 'Axillary nodes', a relative site e.g. 'Sentinel nodes', 'Apical node', 'Regional nodes' or a individual node.
Tissue available	Tissue available: Has the appropriate lymph node tissue been made available for examination? Present Absent
Tumour involvement	Tumour involvement: Findings of lymph node involvement with tumour. Present Absent Equivocal Indeterminate
Nature of involvement	Nature of involvement: Nature or grade of the tumour, if present. Focal Diffuse Complete Indeterminate
Route of involvement	Route of involvement: The route by which the tumour became involved in lymph node tissue. Direct spread Metastasis
Number of nodes examined	Number of nodes examined: Number of nodes examined. >=0
Number of nodes with tumour	Number of nodes with tumour: Number of nodes which show tumour involvement. >=0
Extent of tumour	Extent of tumour: Extent of tumour expressed as a maximum length. Applies only to an individual node. >=0 mm
Extra-nodal extension	Extra-nodal extension: Findings related to extension of tumour external to the nodal capsule.
Extra-capsular extension	Extra-capsular extension: Findings of extension of tumour beyond a node capsule. Present Absent Equivocal Indeterminate
Extent of extranodal tumour	Extent of extranodal tumour: Extent of extranodal tumour expressed as a maximum length. >=0 mm
Description	Description: A text description of lymph node involvement by tumour.
Marker dye uptake	Marker dye uptake: Findings of whether marker dye has been taken up by the lymph node or lymph node group.
Radioactivity count	Radioactivity count: Radioactivity count measured after use of radiocolloid. >=0; >=0 Units: /s /min
Weitere Tumorklassifikation	Weitere Tumorklassifikation: Der Archetyp "Weitere Tumorklassifikation" dient zur Stadieneinteilung maligner Neoplasien nach sonstigen, weiteren Tumorklassifikationen, außer der TNM-Klassifikation.
Name der Klassifikation	Name der Klassifikation: Angabe der Bezeichnung der Klassifikation. Wenn möglich wird die Kodierung der spezifischen Klassifikation mit einer Terminologie bevorzugt.
Weitere Beschreibung	Weitere Beschreibung: Jede zusätzliche Beschreibung für die entsprechende Klassifikation.
Stadium/Gruppe/Grad	Stadium/Gruppe/Grad: Das Stadium/die Gruppe/der Grad der Einstufung der Malignität anhand der Klassifikation.
Datum der Klassifizierungseinteilung	Datum der Klassifizierungseinteilung: Das Datum, an dem die Klassifikation festgestellt wurde.
Auflage der Klassifikation	Auflage der Klassifikation: Die Auflage, auf der die Klassifikation basiert, die für die Beurteilung verwendet wurde.
Kommentar	Kommentar: Ergänzende Beschreibung der weiteren Tumorklassifikation, die nicht in anderen Bereichen erfasst wurde.
Histologie Grading	Histologie Grading: Der Differenzierungsgrad der Tumorzellen wird histologisch beurteilt.
Histologie Grading	Histologie Grading: Histologischer Differenzierungsgrad der Tumorzellen. G1 (Gut differenziert) G2 (Mäßig differenziert) G3 (Schlecht differenziert) G4 (Undifferenziert) Nicht bestimmbar Niedriggradig maligne (G1-G2) Mittelgradig maligne (G2-G3) Hochgradig maligne (G3-G4) Unbekannt Trifft nicht zu Borderline
Pathology interpretation	Pathology interpretation: Single word, phrase of brief description representing the interpretation of the anatomical pathology finding. A coded term is preferred.
Specimen container ID	Specimen container ID: Reference ID, URI or text for a specimen container related to this finding. Identifier URI Text
Tissue available	Tissue available: True if the tissue is available for examination.
Examination description	Examination description: A narrative description of the entire anatomical pathology examination.
Specimen container ID	Specimen container ID: Reference ID, URI or text for a specimen containera related to this finding. Identifier URI Text
Conclusion	Conclusion: Narrative description of the key findings. For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.
Diagnosetext	Diagnosetext: Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result. For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.
Comment	Comment: Additional narrative about the test result not captured in other fields.
Protocol
Laboratory internal identifier	Laboratory internal identifier: A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process. This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test. Identifier Text
Test request details	Test request details: Details about the test request. In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.
Original test requested name	Original test requested name: Name of the original laboratory test requested. This data element is to be used when the test requested differs from the test actually performed by the laboratory.
Requester order identifier	Requester order identifier: The local identifier assigned by the requesting clinical system. Equivalent to the HL7 Placer Order Identifier. Identifier Text
Receiver order identifier	Receiver order identifier: The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS). Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier. Identifier Text
pathologisches TNM Stadium	pathologisches TNM Stadium: A framework for the postsurgical, histopathological classification and grading of malignancies using the TNM system. Designated as pTNM.
Data
Point in time event	Point in time event: Default, unspecified point in time which may be explicitly defined in a template or at run-time.
Data
Cancer type	Cancer type: The type of cancer being assessed. Coding of the type of the cancer with a terminology is strongly preferred.
Anatomical site	Anatomical site: The anatomical site where the assessed cancer is situated.
Anatomical subsite	Anatomical subsite: The anatomical subsite where the assessed cancer is situated.
Primary tumour (pT)	Primary tumour (pT): Assessment of the primary tumour. Designated as 'pT'. Coding with a TNM code appropriate for the identified 'Cancer type' and/or anatomical site is expected. For example: 'pT1'; or 'pT3'.
Multiple primary tumours (m)	Multiple primary tumours (m): Presence of multiple simultaneous primary tumours at a single site. Designated as a suffix, either as the letter 'm' or the number of primary tumours. For example: pT2(m) or pT2(4). Count Boolean
Carcinoma in situ (is)	Carcinoma in situ (is): Presence of carcinoma in situ associated with the primary tumour. Record as true, designated by addition of the suffix 'is'. For example: pT3(m, is) or pT2(3, is) or pT2(is).
Regional lymph nodes (pN)	Regional lymph nodes (pN): Assessment of the regional lymph nodes. Designated as 'pN'. Coding with a TNM code appropriate for the identified 'Cancer type' and/or anatomical site is expected. For example: 'pNX'; or 'pN2'.
Sentinel node (sn)	Sentinel node (sn): Presence of metastasis within one or more sentinel node(s). Record as true, designated by addition of the suffix 'sn'. For example: 'pN0(sn) No sentinel lymph node metastasis' or 'pN1(sn) Sentinel lymph node metastasis'.
Micrometastases (mi)	Micrometastases (mi): Presence of micrometastases in the regional lymph drainage area of the primary tumour. Record as true, designated by addition of the suffix 'mi'. For example: 'pN1(mi)'.
Regional lymph node ITC	Regional lymph node ITC: Presence of isolated tumour cells (ITC) detected by H & E stains or immunohistochemistry in regional lymph nodes. For example 'pN0(i-) No regional lymph node metastasis histologically, negative morphological findings for ITC'; 'pN0(mol+) No regional lymph node metastasis histologically, positive non morphological findings for ITC'; or 'pN0(i+)(sn) No sentinel lymph node metastasis histologically, positive morphological findings for ITC'. i- i+ mol- mol+
Distant metastasis (pM)	Distant metastasis (pM): Assessment of distant metastasis. Designated as 'pM'. Coding with a TNM code appropriate for the identified 'Cancer type' and/or anatomical site is expected. For example: 'pM1'; or 'pM0'.
Distant metastasis ITC	Distant metastasis ITC: Presence of isolated tumour cells (ITC) detected by H & E stains or immunohistochemistry in distant metastases, such as bone marrow. For example: 'pM0(i+)' or 'pM0(mol+)'. i- i+ mol- mol+
Histopathological grade (G)	Histopathological grade (G): Histopathological grading of the tumour. Coding with a TNM code appropriate for the identified 'Cancer type' and/or anatomical site is expected. For example: 'GX'; 'high grade' or 'low grade'.
Residual tumour (R)	Residual tumour (R): Assessment of the presence of residual tumour after treatment. For example: 'R1 (Microscopic residual tumour)'. RX R0 R1 R2
Lymphatic invasion (L)	Lymphatic invasion (L): Assessment of invasion into the lymphatic system. For example: 'L0 (No lymphatic invasion)'. LX L0 L1
Venous invasion (V)	Venous invasion (V): Assessment of invasion into the venous system. For example: 'V1 (Microscopic venous invasion)'. VX V0 V1 V2
Perineural invasion (Pn)	Perineural invasion (Pn): Assessment of invasion into the space surrounding nerves. For example: 'Pn0 (No perineural invasion)'. PnX Pn0 Pn1
Multimodality therapy (y)	Multimodality therapy (y): Assessment is performed during or following initial multimodality therapy. Record as true, designated by addition of the prefix 'y'. For example: 'yTNM'.
Recurrent (r)	Recurrent (r): Assessment is performed for a recurring cancer after a disease-free interval. Record as true, designated by addition of the prefix 'r'.
Autopsy (a)	Autopsy (a): Assessment is performed by postmortem examination after the death of the patient. Record as true, designated by addition of the prefix 'a'.
pTNM assessment	pTNM assessment: Concatenation of 'pT', 'pN' and 'pM' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable.
Stage grouping	Stage grouping: The staging of the TNM assessment.
Protocol
TNM Edition	TNM Edition: The edition of the TNM classification system used for the assessment. Default value: 8. Auflage der „TNM-Klassifikation maligner Tumoren“
Histopathologische Diagnose	Histopathologische Diagnose: 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. 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'.
Data
Diagnose (Tumor Morphologie ICD-O)	Diagnose (Tumor Morphologie ICD-O): Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Value set: terminology://www.dimdi.de/static/de/klassifikationen/icd/icd-o-3/icdo3rev1html/chapter-m.htm
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Körperstelle (Tumor Topographie ICD-O)	Körperstelle (Tumor Topographie ICD-O): Identification of a simple body site for the location of the problem or diagnosis. 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. Value set: terminology://www.dimdi.de/static/de/klassifikationen/icd/icd-o-3/icdo3rev1html/chapter-t.htm
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Other contributors	Katrin Tröltzsch, Heidelberg University Hospital, Germany