| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=oBDS_SYST, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, 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]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., 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[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. 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- Hormontherapie
- Immun-/Antikörpertherapie
- zielgerichtete Substanzen
- Chemo- + Immun-/Antikörpertherapie
- Chemotherapie + zielgerichtete Substanzen
- Chemo- + Immun-/Antikörpertherapie + zielgerichtete Substanzen
- Immun-/Antikörpertherapie + zielgerichtete Substanzen
- Stammzelltransplantation (inkl. Knochenmarktransplantation)
- Active Surveillance
- Wait and see
- Watchful Waiting
- Sonstiges
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Meldeanlass, description=The clinical or process-related reason for the procedure., comment=Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- behandlungsbeginn
- behandlungsende
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0048], code=at0048, itemType=ELEMENT, level=3, text=Ende_Grund, description=Outcome of procedure performed., comment=Coding with a terminology is preferred, where possible., 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- reguläres Ende
- reguläres Ende mit Dosisreduktion
- reguläres Ende mit Substanzwechsel
- Abbruch wegen Nebenwirkungen
- Abbruch wegen Progress
- Abbruch aus sonstigen Gründen
- Patient verweigert weitere Therapie
- Patient verstorben
- unbekannt
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- Abbruch wegen Progress
- Abbruch aus sonstigen Gründen
- keine Angabe
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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.relation_to_operation.v1], code=at0000, itemType=CLUSTER, level=3, text=Relation zur OP, description=Zur Darstellung des Bezugs einer Strahlentherapie, systemischen Therapie und/oder sonstigen Therapie zu einer operativen Therapie (OP)., 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-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.relation_to_operation.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Stellung_OP, description=Der Bezug einer Strahlentherapie, einer systemischen Therapie oder einer sonstigen Therapie zu einer operativen Therapie (OP)., 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- Neoadjuvant
- Adjuvant
- Ohne Bezug zur OP
- Intraoperativ
- Alleinige Therapie
- Sonstiges
- Unbekannt
- ohne Bezug zu einer operativen Therapie
- adjuvant
- neoadjuvant
- intraoperativ
- Sonstiges
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- 1: Grade 1
- 2: Grade 2
- 3: Grade 3
- 4: Grade 4
- 5: Grade 5
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[openEHR-EHR-CLUSTER.ctcae.v1]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=CTCAE version, description=The version of the CTCAE terminology used., 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- CTCAE Version 4
- CTCAE Version 4.03
- CTCAE Version 5.0
- Falls andere bzw. ältere Versionen verwendet werden
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1], code=at0000, itemType=SECTION, level=1, text=Substanz, 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]/items[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=2, text=Medication management, description=Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item., comment=This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, 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]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Bezeichnung, description=Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity., comment=For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'.
It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available., 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]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2], code=at0000, itemType=CLUSTER, level=4, text=Medication details, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., 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]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0132], code=at0132, itemType=ELEMENT, level=5, text=ATC Code, description=The name of the medication or medication component., comment=For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null]], templateType=normal] |