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values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.modul_dkkr.v0]/items[at0010]/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=5, text=GPOH_Therapiestudienname, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.modul_dkkr.v0]/items[at0010]/items[at0014]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=GPOH_Therapiestudiennummer, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.modul_dkkr.v0]/items[at0010]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=Syndrom_oder_sonstiges, description=*, 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-SECTION.adhoc.v1 and name/value='Verlauf'], code=at0000, itemType=SECTION, level=1, text=Verlauf, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=2, text=Procedure, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Procedure name, description=Identification of the procedure by name., comment=Coding of the specific procedure with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Verlaufsuntersuchung, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0066], code=at0066, itemType=ELEMENT, level=4, text=Untersuchungsdatum_Verlauf, description=The date and/or time on which the procedure is intended to be performed., comment=Only for use in association with the 'Procedure scheduled' pathway step., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Meldeanlass, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- statusaenderung
- statusmeldung
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053], code=at0053, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[at0054], code=at0054, itemType=ELEMENT, level=4, text=Verlauf_ID, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service., comment=This is equivalent to Placer Order Number in HL7 v2 specifications., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text Identifier
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tumour_status.v1], code=at0000, itemType=CLUSTER, level=4, text=Tumorstatus, description=Status der Tumorerkrankung im Verlauf oder nach dem Ende der Therapie bzw. der Nachsorge., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tumour_status.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Verlauf_Lokaler_Tumorstatus, description=Der Zustand vom Primärtumor wird beurteilt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- K = Kein Tumor nachweisbar
- T= Tumorreste (Residualtumor)
- P= Tumorreste Residualtumor Progress
- N= Tumorreste Residualtumor No Change
- R= Lokalrezidiv
- F= Fraglicher Befund
- U= Unbekannt
- X= Fehlende Angabe
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tumour_status.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Verlauf_Tumorstatus_Fernmetastasen, description=Beurteilung der Situation im Bereich der Fernmetastasen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms- K = Keine Fernmetastasen nachweisbar
- M = Verbliebene Fernmetastase(n)
- R = Neu aufgetretene Fernmetastase(n) bzw. Metastasenrezidiv
- T = Fernmetastasen Residuen
- P = Fernmetastasen Progress
- N = Fernmetastasen No Change
- F = Fraglicher Befund
- U = Unbekannt
- X = Fehlende Angabe
- keine Fernmetastasen nachweisbar
- Fernmetastasenl Residuen
- Fernmetastasen Progress
- Fernmetastasen No Change
- neu aufgetretene Fernmetastase(n) bzw. Metastasenrezidiv
- fraglicher Befund
- unbekannt
- fehlende Angabe
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tumour_status.v1]/items[at0033], code=at0033, itemType=ELEMENT, level=5, text=Verlauf_Tumorstatus_Lymphknoten, description=Beurteilung der Situation im Bereich der regionären Lymphknoten., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms- K = Kein Lymphknotenbefall nachweisbar
- R = Neu aufgetretenes Lymphknotenrezidiv
- T = bekannter Lymphknotenbefall Residuen
- N = bekannter Lymphknotenbefall No Change
- F = Fraglicher Befund
- U = Unbekannt
- X = Fehlende Angabe
- keine Fernmetastasen nachweisbar
- Fernmetastasenl Residuen
- Fernmetastasen Progress
- Fernmetastasen No Change
- neu aufgetretene Fernmetastase(n) bzw. Metastasenrezidiv
- fraglicher Befund
- unbekannt
- fehlende Angabe
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tumour_status.v1]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Gesamtbeurteilung Tumorstatus, description=Gesamtbeurteilung der Erkrankung unter Berücksichtigung aller Manifestationen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms- V= Vollremission (complete remission, CR)
- T= Teilremission / mindestens 50% Rückgang des Tumors (partial remission, PR)
- K= Keine Änderung (no change, NC) = stable disease
- P= Progression
- D= Divergentes Geschehen
- B= Klinische Besserung des Zustandes, Kriterien für Teilremission jedoch nicht erfüllt (minimal response, MR)
- R= Vollremission mit residualen Auffälligkeiten (CRr)
- U= Beurteilung unmöglich
- X= Fehlende Angabe
- Vollremission (complete remission, CR)
- Fernmetastasenl Residuen
- keine Fernmetastasen nachweisbar
- Fernmetastasen Progress
- divergentes Geschehen
- klinische Besserung des Zustandes, Kriterien für Teilremission jedoch nicht erfüllt (minimal response, MR)
- neu aufgetretene Fernmetastase(n) bzw. Metastasenrezidiv
- Rezidiv
- unbekannt
- fehlende Angabe
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1], code=at0000, itemType=CLUSTER, level=4, 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Name, 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Stadium, 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Datum, 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.evidence_classification.v0], code=at0000, itemType=CLUSTER, level=4, text=Evidenzgraduierung, description=Dieser Archetyp dient der Dokumentation einer klinischen Bewertung von einer oder mehreren genetischen Varianten., comment=Die Bewertung einer oder mehrerer genetischer Varianten mithilfe von standardisierten Skalierungen., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059], code=at0059, itemType=CLUSTER, level=5, text=Genetische Variation, description=Beschreibung der genetischen Variation, auf welche sich die Evidenzgraduierung bezieht. Sollte sich die Evidenzgraduierung auf mehrere genetische Varianten (auch innerhalb desselben Gens) beziehen, muss jede Variation einzeln festgehalten werden., comment=Die Variante kann aus dem molekularpathologischen Bericht, oder aber auch aus einer externen Datenbank stammen., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059]/items[at0060], code=at0060, itemType=ELEMENT, level=6, text=Bezeichnung, description=Der vollständige, vom HGNC genehmigte Genname. Es soll der Genname angegeben werden, in welchem die Variation gefunden wurde., comment=Zum Beispiel: Chromodomain helicase DNA binding protein 5, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059]/items[at0080], code=at0080, itemType=ELEMENT, level=6, text=Auspraegung, description=Das offizielle, vom HGNC genehmigte Gensymbol, welches eine Kurzform des Gennamens ist., comment=Zum Beispiel: CHD5, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms- Mutation/positiv
- Wildtyp/nicht mutiert/negativ
- Polymorphismus
- nicht bestimmbar
- unbekannt
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059]/items[at0040], code=at0040, itemType=ELEMENT, level=6, text=Sonstige_Auspraegung, description=Ein Verweis auf die Variante, die bewertet werden soll. Die Variante sollte immer nach der HGVS Nomenklatur annotiert werden. Die Variante sollte auf Proteinebene angegeben werden. Ist eine Region betroffen, die nicht für ein Protein kodiert, so ist die Variante auf DNA Ebene anzugeben., comment=Zum Beispiel:
Protein Nomenklatur: p.G388A oder Gly388Arg
DNA Nomenklatur: c.5249C>T, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1], code=at0000, itemType=CLUSTER, level=4, text=TNM clinical classification, description=A framework for the clinical classification and stage grouping of malignancies using the TNM system., comment=Designated as TNM or cTNM., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Primary tumour (T), description=Assessment of the the extent of the primary tumour., comment=Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'T1'; or 'cT3'. Represented as 'T' or 'cT' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Regional lymph nodes (N), description=Assessment of the the absence or presence and extent of regional lymph node metastasis., comment=Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'NX'; or 'cN2'. Represented as 'N' or 'cN' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Distant metastasis (M), description=Assessment of the absence or presence of distant metastasis., comment=Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'M1'; 'cM1a'; 'M1 PUL'; or 'cM0'. Represented as 'M' or 'cM' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R2 (Macroscopic residual tumour)'. Represented as 'R' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'. Represented as 'L' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'. Represented as 'V' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'. Represented as 'Pn' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=5, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Represented by the suffix, either as '(m)' or the number of primary tumours added to the T code in brackets . For example: 'T2(m)' or 'cT2(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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=5, text=Multimodality therapy (y), description=Record as True if assessment is performed during or following initial multimodal therapy., comment=Represented by the prefix 'y' added to the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=5, text=Recurrent (r), description=Record as True if assessment is performed for a recurring cancer after a disease-free interval., comment=Represented by the prefix 'r' added to the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Autopsy (a), description=Record as True if assessment is performed at postmortem examination., comment=Represented by the prefix 'a' added to the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0031], code=at0031, itemType=ELEMENT, level=5, text=Stage grouping, description=The categorisation of the anatomical stage of the tumour, usually based on TNM assessment., comment=For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=TNM Edition, description=The edition of the TNM classification system used for the 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1], code=at0000.1, itemType=CLUSTER, level=4, text=TNM pathological classification, description=A framework for the pathological classification and stage grouping of malignancies using the TNM system., comment=Designated as pTNM., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0003.1], code=at0003.1, itemType=ELEMENT, level=5, text=Primary tumour (pT), description=Assessment of the extent of the primary tumour., comment=Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'pT1'; or 'pT3'. Represented as 'pT' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0004.1], code=at0004.1, itemType=ELEMENT, level=5, text=Regional lymph nodes (pN), description=Assessment of the absence or presence and extent of regional lymph node metastasis., comment=Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'pNX'; or 'pN2'. Represented as 'pN' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0005.1], code=at0005.1, itemType=ELEMENT, level=5, text=Distant metastasis (pM), description=Assessment of the absence or presence of distant metastasis., comment=Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'pM1'. Represented as 'pM' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R2 (Macroscopic residual tumour)'. Represented as 'R' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'. Represented as 'L' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'. Represented as 'V' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'. Represented as 'Pn' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0025.1], code=at0025.1, itemType=ELEMENT, level=5, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Represented by the suffix, either as '(m)' or the number of primary tumours added to the T code. For example: 'pT2(m)' or 'pT2(4)'. Represented as 'pm' within the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=5, text=Multimodality therapy (y), description=Record as True if assessment is performed during or following initial multimodal therapy., comment=Represented by the prefix 'y' added to the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=5, text=Recurrent (r), description=Record as True if assessment is performed for a recurring cancer after a disease-free interval., comment=Represented by the prefix 'r' added to the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Autopsy (a), description=Record as True if assessment is performed at postmortem examination., comment=Represented by the prefix 'a' added to the 'TNM assessment'., 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-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0031.1], code=at0031.1, itemType=ELEMENT, level=5, text=Stage grouping, description=The categorisation of the anatomical stage of the tumour, usually based on pTNM assessment., comment=For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Verlauf']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=TNM Edition, description=The edition of the TNM classification system used for the 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-SECTION.adhoc.v1 and name/value='Fernmetastase'], code=at0000, itemType=SECTION, level=1, text=Fernmetastase, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Fernmetastase']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, 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-SECTION.adhoc.v1 and name/value='Fernmetastase']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Fernmetastase']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: local::399409002::Fernmetastase, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Fernmetastase']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0079], code=at0079, itemType=ELEMENT, level=4, text=Variant, description=Specific variant or subtype of the Diagnosis, if relevant., comment=For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible., 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-SECTION.adhoc.v1 and name/value='Fernmetastase']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Lokalisation, 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=Terminology: local_terms- Lunge
- Knochen
- Leber
- Hirn
- Lymphknoten
- Knochenmark
- Pleura
- Peritoneum
- Nebennieren
- Haut
- Andere Organe
- Generalisierte Metastasierung
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- 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
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ICD-O-3 is a dual classification. It contains both a topographical code and a histological code for each neoplasm.
The topographical describes the site of the neoplasm; in general, it uses the same three- or four-character codes as used in ICD-10 for malignant neoplasms. This results in a greater accuracy in the encoding of the topography of benign tumors than achieved in ICD-10.
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4 digits – Cell type (histology)
1 digit – Behavior
1 digit – Grade, differentiation or phenotype
In ICD-O morphology codes, a common root codes the cell type of a given tumor, while an additional digit codes the behavior. 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description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Histologie']/items[openEHR-EHR-OBSERVATION.story.v1]/protocol[at0007]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Tumor_Histologiedatum, description=*, 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-SECTION.adhoc.v1 and 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occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Histologie']/items[openEHR-EHR-OBSERVATION.story.v1]/protocol[at0007]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Sentinel_LK_befallen, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.ecog.v1], code=at0000, itemType=OBSERVATION, level=1, text=ECOG performance status, description=A scale used by clinicians to assess the functional performance status of a patient with a diagnosis of cancer. Also known as the WHO performance status or Zubrod performance status., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.ecog.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-OBSERVATION.ecog.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event 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=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.ecog.v1]/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.ecog.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=ECOG performance status, description=The functional performance status of a patient with a diagnosis of cancer., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 0: Asymptomatic
- 1: Symptomatic, fully ambulatory
- 2: Symptomatic, in bed <50% of the day
- 3: Symptomatic, in bed >50% of the day (but not bedridden)
- 4: Bedridden
- 5: Dead
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.karnofsky_index.v1], code=at0000, itemType=OBSERVATION, level=1, text=Karnofsky Performance Status Scale, description=A scale used by clinical personnel to record symptom-related Not to be used to record examination results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.karnofsky_index.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-OBSERVATION.karnofsky_index.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.karnofsky_index.v1]/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.karnofsky_index.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Performance Status, description=Symptom-related limitations of activity, self-care and self-determination of cancer patients., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 0: Dead
- 10: Moribund
- 20: Very sick
- 30: Severely disabled
- 40: Disabled
- 50: Requires occasional assistance
- 60: Requires occasional assistance
- 70: Cares for self
- 80: Normal activity with effort
- 90: Able to carry on normal activity
- 100: Normal no complaints
, extendedValues=null]], templateType=normal] |