TEMPLATE Strahlentherapie (Strahlentherapie)

TEMPLATE IDStrahlentherapie
ConceptStrahlentherapie
DescriptionZur Repräsentation von Daten zu einer Strahlentherapie eines Patienten mit einer onkologischen Diagnose im HiGHmed Projekt.
UseDieses Template wird verwendet, um Daten zu einer Strahlentherapie von Patienten mit einer onkologischen Diagnose zu verzeichnen. Es sollen folgende Daten zu der Strahlentherapie wie Lokalisation der Bestrahlung, Beginn und Ende, Applikationsart, Strahlenart, Dosis, Fraktionen, Art der Bildgebung, Relation zur OP, Grund für das Ende der Therapie, Gesamtansprechen, Anmerkungen und Intention erfasst werden.
MisuseDieses Template soll nicht verwendet werden, um andere Therapien oder Prozeduren des Patienten zu verzeichnen. Für diese Daten sind jeweils andere Templates zu benutzen.
PurposeZur Repräsentation von Daten zu einer Strahlentherapie eines Patienten mit einer onkologischen Diagnose im HiGHmed Projekt.
References
Authorsdate: 2019-12-03; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Alina Rehberg
Other Details Languagedate: 2019-12-03; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Alina Rehberg
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: openEHR Foundation
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • PARENT:MD5-CAM-1.0.1: 641B268BE8805CEB8DC21AB82C53AB3F
  • MD5-CAM-1.0.1: b43be0e51396c1cab7de6264054d1df0
  • Original Language: ISO_639-1::de
  • Sem Ver: 4.0.0
KeywordsStrahlentherapie; Radiatio; Radiotherapie; Bestrahlung; Brachytherapie; Radioonkologie; Radio-/Chemotherapie; Strahlenbehandlung; Teletherapie; Radioonkologie; Radionuklidentherapie; Metabolische Therapie
Language useden
Citeable Identifier1246.169.291
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
StrahlentherapieStrahlentherapie: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report IDReport ID: Identification information about the report.
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
  • Zwischenbericht
  • Endbericht
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.
StrahlentherapieStrahlentherapie: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Description
Procedure nameProcedure name: Identification of the procedure by name.
Coding of the specific procedure with a terminology is preferred, where possible.
  • Strahlentherapie
DescriptionDescription: Narrative description about the procedure, as appropriate for the pathway step.
For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.
Relation zur OPRelation zur OP: Zur Darstellung des Bezugs einer Strahlentherapie, systemischen Therapie und/oder sonstigen Therapie zu einer operativen Therapie (OP).
Stellung zur OPStellung zur OP: Der Bezug einer Strahlentherapie, einer systemischen Therapie oder einer sonstigen Therapie zu einer operativen Therapie (OP).
  • Neoadjuvant 
  • Adjuvant 
  • Ohne Bezug zur OP 
  • Intraoperativ 
  • Alleinige Therapie 
  • Sonstiges 
  • Unbekannt 
TherapieansprechenTherapieansprechen: Bewertung des Ansprechens einer Erkrankung auf die Therapie. Dies hilft dabei, den Erfolg der Behandlung, z.B. einer Strahlen- oder Chemotherapie bei einer Tumorerkrankung zu beurteilen.
GesamtansprechenGesamtansprechen: Ausdruck, der das Ansprechen auf die Behandlung einer Erkrankung beschreibt.
Es handelt sich um eine bereits kodierte Terminologie des Ansprechens auf z.B. eine onkologische Therapie. Ausprägungen können beispielsweise CR (Vollremisson der Erkrankung), PR (Teilremission), SD (Stabile Erkrankung) oder PD (Progression der Erkrankung) sein.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapieansprechen
KommentarKommentar: Kommentarfeld zum Therapieansprechen.
IrradiationIrradiation: Detailed information about the irradiation in radiotherapy.
Anatomical locationAnatomical location: A physical site on or within the human body.
ZielgebietZielgebiet: Identification of a single physical site either on, or within, the human body.
This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent.
Terminology: Zielgebietsschlüssel
  • ZNS 
  • Ganzhirn 
  • Teilhirn 
  • Neuroachse 
  • Kopf-Hals mit/ ohne Lymphknotenregion (+/-) 
  • Orbita (+/-) 
  • Nase/ Nasennebenhöhle (+/-) 
  • Mundhöhle (+/-) 
  • Ohr (+/-) 
  • Speicheldrüse (+/-) 
  • Pharynx (+/-) 
  • Larynx (+/-) 
  • Schilddrüse (+/-) 
  • Halslymphknoten (also ohne Primärtumor) 
  • Thorax mit /ohne Lymphknotenregion (+/-) 
  • Mamma als Ganzbrust (+/-) 
  • Mamma als Teilbrust (+/-) 
  • Brustwand (z.B. Rezidiven n. Ablatio Sarkome) (+/-) 
  • Lunge (+/-) 
  • Ösophagus (+/-) 
  • Thymus (+/-) 
  • Mediastinale Lymphknoten (also ohne Primärtumor) 
  • Abdomen (ohne Becken) mit /ohne Lymphknotenregion (+/-) 
  • Magen (+/-) 
  • Pankreas (+/-) 
  • Leber (+/-) 
  • Milz (+/-) 
  • Niere (+/-) 
  • Nebenniere (+/-) 
  • Retroperitoneale Lymphknoten (also ohne Primärtumor) 
  • Retroperitoneum (z.B. Sarkome); (+/-) 
  • Bauchwand (z.B. Sarkome) (+/-) 
  • Becken mit/ ohne Lymphknotenregion(+/-) 
  • Rektum (+/-) 
  • Analbereich (+/-) 
  • Harnblase (+/-) 
  • Prostata (+/-) 
  • Hoden (+/-) 
  • Penis (+/-) 
  • Uterus/Zervix (+/-) 
  • Uterus 
  • Zervix 
  • Ovar (+/-) 
  • Vulva (+/-) 
  • Vagina (+/-) 
  • Beckenwand (+/-) 
  • Beckenlymphknoten (ohne Primärtumor) 
  • Stütz-/Bewegungsapparat 
  • Schädelknochen 
  • Rippen 
  • Sternum 
  • HWS 
  • BWS 
  • LWS 
  • knöchernes Becken 
  • Hüfte 
  • Achsel 
  • Oberarm 
  • Unterarm 
  • Hand 
  • Leiste 
  • Oberschenkel 
  • Unterschenkel 
  • Fuß 
  • Haut (+/-) 
  • Primärer Hauttumor (auch kutane Lymphome) 
  • Hautmetastasen 
  • Sonstiges: 
  • Ganzkörperbestrahlung 
  • Mantelfeldbestrahlung 
Seite ZielgebietSeite Zielgebiet: Narrative description that can be used to further refine and support the 'Body site name'.
For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area.
Terminology: seite zielgebiet
  • links 
  • rechts 
  • beidseitig 
  • mittig 
  • kein paariges Organ 
  • unbekannt 
StartStart: The date, on which the radiotherapy of the target region was started.
EndEnd: The date, on which the radiotherapy of the target region was ended.
Treatment methodTreatment method: Description of the technical procedure. Depending on how the radiation penetrates the body, different methods of irradiation are distinguished.
  • Teletherapy 
  • Brachytherapy 
  • Other therapy 
Application typeApplication type: Irradiation technique, as a further classification of the treatment method.
The techniques of irradiation are diverse. If possible, encoding with a terminology is preferred.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/applikationsart-strahlentherapie
Type of radiationType of radiation: Type of radiation according to its components.
More than one radiation type can be selected.
  •  Coded Text
    • Photons (ɣ) 
    • Electrons (e-) 
    • Neutrons (n) 
    • Protons (p+) 
    • Helium ions 
    • Carbon ions 
    • Alpha rays (α) 
    • Beta rays (β) 
    • Gamma rays (γ) 
  •  Text
Single doseSingle dose: The single dose used to irradiated the target region. The dose refers to the prescribed isodose (equal energy or ion dose on a line or area).
Dose (ED)Dose (ED): The value of the single dose.
Example: When specifying radiation dose 3.0 Gy, the value is '3.0'.
0..999.999
Unit (ED)Unit (ED): The unit in which the single dose was specified.
The individual dose in radiation therapy is usually recorded in grays (Gy) and less frequently in gigabequerels (GBq). For a radiation dose of '3.0 Gy', the unit for the dose is 'Gy'. For a radiation dose of '2.6 GBq', the unit for the dose is 'GBq'.
  • Gy 
  • GyE 
  • kBq 
Total doseTotal dose: The total dose used to irradiate the target region.
The total dose is composed of several individual doses (fractions). For example: 30.0 Gy can be administered in 10 fractions of 3.0 Gy each.
Dose (SD)Dose (SD): The value of the total dose.
Example: When indicating radiation dose of 30.0 Gy, the value is '30.0'.
0..999.999
Unit (SD)Unit (SD): The unit in which the total dose was specified.
The individual dose in radiation therapy is usually recorded in grays (Gy) and less frequently in gigabequerels (GBq). For a radiation dose of '30.0 Gy', the unit for the dose is 'Gy'. For a radiation dose of '26.0 GBq', the unit for the dose is 'GBq'.
  • Gy 
  • GyE 
  • kBq 
Number of dose fractionsNumber of dose fractions: The number of fractions (individual doses) to which the total dose was allocated.
NebenwirkungenNebenwirkungen: Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign nameSymptom/Sign name: The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Common Terminology Criteria for Adverse Events (CTCAE)Common Terminology Criteria for Adverse Events (CTCAE): A framework for recording any unfavourable and unintended sign, symptom or disease temporally using the CTCAE terminology.
System Organ Class (SOC)System Organ Class (SOC): The category of the 'Term' in the MedDRA hierarchy.
Identified as a MedDRA primary class - representing an anatomical or physiological system, aetiology or purpose.
TermTerm: The name of the sign, symptom or disease observed.
Identified as a MEDRAterm and corresponding code.
GradeGrade: The severity of the Adverse event.
For each Grade, non-specific comments provide some general guidance about the severity for each grade and are represented within square brackets []. In practice, each grade will be represented by a specific clinical description, appropriate for the selected term and will likely be sourced from an external knowledgebase or resource.
  • 1: Grade 1 
  • 2: Grade 2 
  • 3: Grade 3 
  • 4: Grade 4 
  • 5: Grade 5 
CTCAE versionCTCAE version: The version of the CTCAE terminology used.
Ende GrundEnde Grund: Outcome of procedure performed.
Coding with a terminology is preferred, where possible.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapieende-grund
IntentionIntention: Reason that the activity or care pathway step for the identified procedure was carried out.
For example: the reason for the cancellation or suspension of the procedure.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/intention-der-therapie
AnmerkungenAnmerkungen: Additional narrative about the activity or care pathway step not captured in other fields.
Protocol
Strahlentherapie IDStrahlentherapie ID: The local ID assigned to the order by the healthcare provider or organisation requesting the service.
This is equivalent to Placer Order Number in HL7 v2 specifications.
  •  Text
  •  Identifier
BestrahlungsplanungBestrahlungsplanung: Clinical activity about performing an imaging examination.
Description
Art der Bildgebung zur BestrahlungsplanungArt der Bildgebung zur Bestrahlungsplanung: The name of the examination (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible.
  • Sonographie
  • CT
  • MRT
  • DSA
  • PET-CT
  • [...]
Protocol
Start date/timeStart date/time: The start date and/or time for the procedure. This will indicate the scheduled date/time when recorded against the 'Appointment scheduled' care pathway step or the actual Start date/time in the 'Examination performed' step.
Tumordiagnose_sectionTumordiagnose_section: Framework for consistent modelling of content within a template for a Problem list.
Intended to be used within the COMPOSITION.problem_list.
TumordiagnoseTumordiagnose: 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 Name (ICD-10)Diagnose Name (ICD-10): Identification of the problem or diagnosis, by name.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Diagnose BeschreibungDiagnose Beschreibung: 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.
ErstdiagnosedatumErstdiagnosedatum: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Protocol
Tumor IDTumor ID: Zur Darstellung der ID des Tumors.
Tumor IDTumor ID: Die ID/Kennung des Tumors.