TEMPLATE Histopathologischer Befund_alternativ (Histopathologischer Befund_alternativ)

TEMPLATE IDHistopathologischer Befund_alternativ
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=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, PARENT:MD5-CAM-1.0.1=55DB2D45BC470E831EE8C905348471E4, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.highmed, MD5-CAM-1.0.1=31b87dc2aee97c11f9d97b3525337f27, build_uid=884ff6bd-ce65-4268-a9f2-6731eca57c5f}
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'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Pathologisch-anatomische Begutachtung mit kritischer Stellungnahme, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0073], code=at0073, itemType=ELEMENT, level=5, text=Overall test status, description=The status of the laboratory test result as a whole., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Registered 
    • Partial 
    • Preliminary 
    • Final 
    • Amended 
    • Corrected 
    • Appended 
    • Cancelled 
    • Entered in error 
  •  Text
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  •  Coded Text
    • Macroscopic examination 
    • Microscopic examination 
  •  Text
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  • Present 
  • Absent 
  • Equivocal 
  • Indeterminate 
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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., 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  • Present 
  • Absent 
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  • Present 
  • Absent 
  • Equivocal 
  • Indeterminate 
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  • Focal 
  • Diffuse 
  • Complete 
  • Indeterminate 
, 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[at0046], code=at0046, itemType=ELEMENT, level=8, text=Route of involvement, description=The route by which the tumour became involved in lymph node tissue., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Direct spread 
  • Metastasis 
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  • Present 
  • Absent 
  • Equivocal 
  • Indeterminate 
, 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[at0039]/items[at0014], code=at0014, itemType=ELEMENT, level=9, text=Extent of extranodal tumour, description=Extent of extranodal tumour expressed as a maximum length., 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.lymph_node_metastases.v0]/items[at0040], code=at0040, itemType=ELEMENT, level=8, text=Description, description=A text description of lymph node involvement by tumour., 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.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[at0051], code=at0051, itemType=ELEMENT, level=8, text=Marker dye uptake, description=Findings of whether marker dye has been taken up by the lymph node or lymph node group., 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.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[at0052], code=at0052, itemType=ELEMENT, level=8, text=Radioactivity count, description=Radioactivity count measured after use of radiocolloid., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • /s
  • /min
, 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.further_tumor_classification.v1], code=at0000, itemType=CLUSTER, level=7, text=Weitere Tumorklassifikation, description=Der Archetyp "Weitere Tumorklassifikation" dient zur Stadieneinteilung maligner Neoplasien nach sonstigen, weiteren Tumorklassifikationen, außer der TNM-Klassifikation., 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.further_tumor_classification.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=Name der Klassifikation, description=Angabe der Bezeichnung der Klassifikation. Wenn möglich wird die Kodierung der spezifischen Klassifikation mit einer Terminologie bevorzugt., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=Weitere Beschreibung, description=Jede zusätzliche Beschreibung für die entsprechende Klassifikation., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=8, text=Stadium/Gruppe/Grad, description=Das Stadium/die Gruppe/der Grad der Einstufung der Malignität anhand der Klassifikation., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=8, text=Datum der Klassifizierungseinteilung, description=Das Datum, an dem die Klassifikation festgestellt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, 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.further_tumor_classification.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=8, text=Auflage der Klassifikation, description=Die Auflage, auf der die Klassifikation basiert, die für die Beurteilung verwendet wurde., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=8, text=Kommentar, description=Ergänzende Beschreibung der weiteren Tumorklassifikation, die nicht in anderen Bereichen erfasst wurde., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[openEHR-EHR-CLUSTER.histology_grading.v1], code=at0000, itemType=CLUSTER, level=7, text=Histologie Grading, description=Der Differenzierungsgrad der Tumorzellen wird histologisch beurteilt., 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.histology_grading.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=Histologie Grading, description=Histologischer Differenzierungsgrad der Tumorzellen., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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 
, 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[at0010], code=at0010, itemType=ELEMENT, level=7, text=Pathology interpretation, description=Single word, phrase of brief description representing the interpretation of the anatomical pathology finding. A coded term is preferred., comment=null, 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]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[at0017], code=at0017, itemType=ELEMENT, level=7, text=Specimen container ID, description=Reference ID, URI or text for a specimen container related to this finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  URI
  •  Text
, 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[at0006], code=at0006, itemType=ELEMENT, level=7, text=Tissue available, description=True if the tissue is available for examination., comment=null, 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Examination description, description=A narrative description of the entire anatomical pathology examination., 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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0018], code=at0018, itemType=ELEMENT, level=6, text=Specimen container ID, description=Reference ID, URI or text for a specimen containera related to this finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  URI
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=5, text=Conclusion, description=Narrative description of the key findings., comment=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'., 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[at0098], code=at0098, itemType=ELEMENT, level=5, text=Diagnosetext, description=Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result., comment=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'., 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]/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the test result not captured in other fields., comment=null, 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], 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.laboratory_test_result.v1]/protocol[at0004]/items[at0068], code=at0068, itemType=ELEMENT, level=3, text=Laboratory internal identifier, description=A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process., comment=This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test., 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], 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- 
  • i+ 
  • mol- 
  • mol+ 
, 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- 
  • i+ 
  • mol- 
  • mol+ 
, 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 
  • R0 
  • R1 
  • R2 
, 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 
  • L0 
  • L1 
, 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 
  • V0 
  • V1 
  • V2 
, 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 
  • Pn0 
  • Pn1 
, 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= Value set: 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= Value set: 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 
    • Probable 
    • Confirmed 
  •  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]