TEMPLATE Histopathologischer Befund_alternativ (482a8f30-a9c6-4b34-84a4-e068b97cfe47)

TEMPLATE ID482a8f30-a9c6-4b34-84a4-e068b97cfe47
ConceptHistopathologischer Befund_alternativ
DescriptionDas Template dient zur Erfassung der pathologisch-anatomischen Begutachtung mit kritischer Stellungnahme.
UseZur Repräsentation der pathologisch-anatomischen Begutachtung mit kritischer Stellungnahme.
MisuseNicht zur Repräsentation anderer pathologischer Befunde bestimmt.
PurposeDas Template dient zur Erfassung der pathologisch-anatomischen Begutachtung mit kritischer Stellungnahme.
References
Authorsdate: 2019-06-26; name: Aurelie Tomczak; organisation: Institute of Pathology, University Hospital Heidelberg; email: au.tomczak@yahoo.com
Other Details Languagedate: 2019-06-26; name: Aurelie Tomczak; organisation: Institute of Pathology, University Hospital Heidelberg; email: au.tomczak@yahoo.com
OtherDetails Language Independent{licence=licence, custodian_organisation=custodian_organisation, PARENT:MD5-CAM-1.0.1=PARENT:MD5-CAM-1.0.1, original_namespace=original_namespace, original_publisher=original_publisher, custodian_namespace=custodian_namespace, MD5-CAM-1.0.1=MD5-CAM-1.0.1, build_uid=build_uid}
KeywordsReport; Befund; Histologie; Histopathologie; Pathologie; pTNM; Grading
Language useden
Citeable Identifier1246.169.231
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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'. 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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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Registered  [The existence of the test is registered in the Laboratory Information System, but there is nothing yet available.]
    • Partial  [This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.]
    • Preliminary  [Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.]
    • Final  [The Test result is complete and verified by an authorised person.]
    • Amended  [The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.]
    • Corrected  [The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.]
    • Appended  [Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.]
    • Cancelled  [The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').]
    • Entered in error  [The Test Result has been withdrawn following previous Final release.]
  •  Text
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  •  Coded Text
    • Macroscopic examination  [Findings recorded on examination of a gross specimen.]
    • Microscopic examination  [Findings recorded after microsopic examination.]
  •  Text
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  • Present  [Ttumour is present at the surgical resection margin.]
  • Absent  [Tumour is absent from the surgical resection margin.]
  • Equivocal  [Presence of tumour at the surgical resection margin is equivocal.]
  • Indeterminate  [Presence of tumour at surgical resection margins has not been determined.]
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[path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=9, text=Distance from resection margin, description=When tumour is absent, the distance from tumour to the named surgical resection margin., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0008]/items[at0021], code=at0021, itemType=ELEMENT, level=9, text=Tumour name, description=Name of the tumour for which the 'Distance from resection margin' applies., comment=For example: 'Invasive tumour' or 'Cancer in situ'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem 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itemType=CLUSTER, level=7, text=Lymph node metastases, description=To record findings of tumour metastases in lymph nodes., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0041], code=at0041, itemType=ELEMENT, level=8, text=Lymph node site name, description=The name for the lymph node site being reported., comment=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., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0044], code=at0044, itemType=ELEMENT, level=8, text=Tissue available, description=Has the appropriate lymph node tissue been made available for examination?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Lymph node tissue is present.]
  • Absent  [Lymph node tissue is absent.]
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  • Present  [Lymph node involvement with tumour is present.]
  • Absent  [Tumour is absent from the lymph node site.]
  • Equivocal  [Lymph node involvement by tumour is equivocal.]
  • Indeterminate  [Lymph node involvement by tumour has not been determined.]
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  • Focal  [The tumour is of a focal nature.]
  • Diffuse  [The tumour is of a diffuse nature.]
  • Complete  [The node is completely invaded by tumour.]
  • Indeterminate  [The nature of tumour has not been determnined.]
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  • Direct spread  [The tumour involved the lymph node by direct spread.]
  • Metastasis  [The tumour involved the lymph node by metastasis.]
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  • Present  [Extra-capsular involvement by tumour is present.]
  • Absent  [Extra-capsular involvement by tumour is absent.]
  • Equivocal  [Extra-capsular involvement by tumour is equivocal.]
  • Indeterminate  [Extra-capsular involvement by tumour has not been determined.]
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Units:
  • /s
  • /min
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  • G1 (Gut differenziert)  [Die Tumorzellen sind histologisch gut differenziert.]
  • G2 (Mäßig differenziert)  [Die Tumorzellen sind histologisch mäßig differenziert.]
  • G3 (Schlecht differenziert)  [Die Tumorzellen sind histologisch schlecht differenziert.]
  • G4 (Undifferenziert)  [Die Tumorzellen sind histologisch undifferenziert.]
  • Nicht bestimmbar  [Der Differenzierungsgrad der Tumorzellen ist histologisch nicht bestimmbar.]
  • Niedriggradig maligne (G1-G2)  [Die Tumorzellen sind histologisch niedriggradig bösartig differenziert.]
  • Mittelgradig maligne (G2-G3)  [Die Tumorzellen sind histologisch mittelgradig bösartig differenziert.]
  • Hochgradig maligne (G3-G4)  [Die Tumorzellen sind histologisch hochgradig bösartig differenziert.]
  • Unbekannt  [Der histologische Differenzierungsgrad der Tumorzellen ist nicht bekannt.]
  • Trifft nicht zu  [Der histologische Differenzierungsgrad der Tumorzellen trifft nicht zu, z.B. bei Gehirngewebe.]
  • Borderline  [Grenzfall / Borderline (bei Ovarialtumoren).]
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  •  Identifier
  •  URI
  •  Text
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  •  Identifier
  •  URI
  •  Text
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  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=3, text=Test request details, description=Details about the test request., comment=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'., 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.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0106], code=at0106, itemType=ELEMENT, level=4, text=Original test requested name, description=Name of the original laboratory test requested., comment=This data element is to be used when the test requested differs from the test actually performed by the laboratory., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0062], code=at0062, itemType=ELEMENT, level=4, text=Requester order identifier, description=The local identifier assigned by the requesting clinical system., comment=Equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Receiver order identifier, description=The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS)., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0], code=at0000.1, itemType=OBSERVATION, level=1, text=pathologisches TNM Stadium, description=A framework for the postsurgical, histopathological classification and grading of malignancies using the TNM system., comment=Designated as pTNM., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=3, text=Point in time event, description=Default, unspecified point in time which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Cancer type, description=The type of cancer being assessed., comment=Coding of the type of the cancer with a terminology is strongly preferred., 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Anatomical site, description=The anatomical site where the assessed cancer is situated., 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Anatomical subsite, description=The anatomical subsite where the assessed cancer is situated., 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008.1], code=at0008.1, itemType=ELEMENT, level=5, text=Primary tumour (pT), description=Assessment of the primary tumour., comment=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'., 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0018.1], code=at0018.1, itemType=ELEMENT, level=5, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Designated as a suffix, either as the letter 'm' or the number of primary tumours. For example: pT2(m) or pT2(4)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count
  •  Boolean
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0015.1], code=at0015.1, itemType=ELEMENT, level=5, text=Carcinoma in situ (is), description=Presence of carcinoma in situ associated with the primary tumour., comment=Record as true, designated by addition of the suffix 'is'. For example: pT3(m, is) or pT2(3, is) or pT2(is)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0009.1], code=at0009.1, itemType=ELEMENT, level=5, text=Regional lymph nodes (pN), description=Assessment of the regional lymph nodes., comment=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'., 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0.1], code=at0.1, itemType=ELEMENT, level=5, text=Sentinel node (sn), description=Presence of metastasis within one or more sentinel node(s)., comment=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'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0.2], code=at0.2, itemType=ELEMENT, level=5, text=Micrometastases (mi), description=Presence of micrometastases in the regional lymph drainage area of the primary tumour., comment=Record as true, designated by addition of the suffix 'mi'. For example: 'pN1(mi)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0.3], code=at0.3, itemType=ELEMENT, level=5, text=Regional lymph node ITC, description=Presence of isolated tumour cells (ITC) detected by H & E stains or immunohistochemistry in regional lymph nodes., comment=For example 'pN0(i-) No regional lymph node metastasis histologically, negative morphological findings for ITC'; 'pN0(mol+) No regional lymph node metastasis histologically, positive non morphological findings for ITC'; or 'pN0(i+)(sn) No sentinel lymph node metastasis histologically, positive morphological findings for ITC'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • i-  [Negative morphological findings for ITC.]
  • i+  [Positive morphological findings for ITC.]
  • mol-  [Negative non-morphological findings for ITC.]
  • mol+  [Positive non-morphological findings for ITC.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0010.1], code=at0010.1, itemType=ELEMENT, level=5, text=Distant metastasis (pM), description=Assessment of distant metastasis., comment=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'., uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, repeating, 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0.8], code=at0.8, itemType=ELEMENT, level=5, text=Distant metastasis ITC, description=Presence of isolated tumour cells (ITC) detected by H & E stains or immunohistochemistry in distant metastases, such as bone marrow., comment=For example: 'pM0(i+)' or 'pM0(mol+)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • i-  [Negative morphological findings for ITC.]
  • i+  [Positive morphological findings for ITC.]
  • mol-  [Negative non-morphological findings for ITC.]
  • mol+  [Positive non-morphological findings for ITC.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Histopathological grade (G), description=Histopathological grading of the tumour., comment=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'., 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.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R1 (Microscopic residual tumour)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • RX  [Presence of residual tumour cannot be assessed.]
  • R0  [No residual tumour.]
  • R1  [Microscopic residual tumour.]
  • R2  [Macroscopic residual tumour.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0013], code=at0013, itemType=ELEMENT, level=5, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • LX  [Lymphatic invasion cannot be assessed.]
  • L0  [No lymphatic invasion.]
  • L1  [Lymphatic invasion.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • VX  [Venous invasion cannot be assessed.]
  • V0  [No venous invasion.]
  • V1  [Microscopic venous invasion.]
  • V2  [Macroscopic venous invasion.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • PnX  [Perineural invasion cannot be assessed.]
  • Pn0  [No perineural invasion.]
  • Pn1  [Perineural invasion.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0019], code=at0019, itemType=ELEMENT, level=5, text=Multimodality therapy (y), description=Assessment is performed during or following initial multimodality therapy., comment=Record as true, designated by addition of the prefix 'y'. For example: 'yTNM'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=5, text=Recurrent (r), description=Assessment is performed for a recurring cancer after a disease-free interval., comment=Record as true, designated by addition of the prefix 'r'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Autopsy (a), description=Assessment is performed by postmortem examination after the death of the patient., comment=Record as true, designated by addition of the prefix 'a'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0016.1], code=at0016.1, itemType=ELEMENT, level=5, text=pTNM assessment, description=Concatenation of 'pT', 'pN' and 'pM' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.tnm_stage-pathological.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0017], code=at0017, itemType=ELEMENT, level=5, text=Stage grouping, description=The staging of the TNM assessment., 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.tnm_stage-pathological.v0]/protocol[at0004], code=at0004, 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.tnm_stage-pathological.v0]/protocol[at0004]/items[at0023], code=at0023, itemType=ELEMENT, level=3, text=TNM Edition, description=The edition of the TNM classification system used for the assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: 8. Auflage der „TNM-Klassifikation maligner Tumoren“, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=1, text=Histopathologische Diagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Diagnose (Tumor Morphologie ICD-O), 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_CODED_TEXT, bindings=null, values=termset: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Clinical description, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Körperstelle (Tumor Topographie ICD-O), 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Suspected  [The diagnosis has been identified with a low level of certainty.]
    • Probable  [The diagnosis has been identified with a high level of certainty.]
    • Confirmed  [The diagnosis has been confirmed against recognised criteria.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, 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-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], templateType=normal]