TEMPLATE oBDS_Diagnose (oBDS_Diagnose)

TEMPLATE IDoBDS_Diagnose
ConceptoBDS_Diagnose
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2023-08-23; name: Alina Rehberg; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover
Other Details Languagedate: 2023-08-23; name: Alina Rehberg; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover
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=7A42F6892858C51A256733E8288064BA, original_language=ISO_639-1::de, original_namespace=org.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=fec25302d710060f4ebcff699435890b, sem_ver=1.0.0, build_uid=8c7d4bd0-61bb-40a3-88d9-be37a7980038}
Language useden
Citeable Identifier1246.169.3348
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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.modul_dkkr.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=3, text=Meldung_Austausch, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: 1 
  • 2: 2 
  • 9: 9 
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  • 0 
  • 2 
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/bfarm/icd-10-gm
  • (Teilweiser) Verlust der oberen Extremität, beidseitig (Teilweiser) Verlust der oberen Extremität, beidseitig 
  • (Teilweiser) Verlust der unteren Extremität, beidseitig (Teilweiser) Verlust der unteren Extremität, beidseitig 
  • 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 
  • 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 
  • AB0-Isoimmunisierung beim Fetus und Neugeborenen AB0-Isoimmunisierung beim Fetus und Neugeborenen 
  • AB0-Unverträglichkeitsreaktion AB0-Unverträglichkeitsreaktion 
  • Abdominale Aktinomykose Abdominale Aktinomykose 
  • Abdominales Kompartmentsyndrom Abdominales Kompartmentsyndrom 
  • Abdominalgravidität Abdominalgravidität 
  • Abhebung von Netzhautschichten Abhebung von Netzhautschichten 
  • Abhängige (asthenische) Persönlichkeitsstörung Abhängige (asthenische) Persönlichkeitsstörung 
  • Abhängigkeit (langzeitig) vom Aspirator Abhängigkeit (langzeitig) vom Aspirator 
  • Abhängigkeit (langzeitig) vom Respirator Abhängigkeit (langzeitig) vom Respirator 
  • Abhängigkeit (langzeitig) von unterstützenden Apparaten, medizinischen Geräten oder Hilfsmitteln, anderenorts nicht klassifiziert Abhängigkeit (langzeitig) von unterstützenden Apparaten, medizinischen Geräten oder Hilfsmitteln, anderenorts nicht klassifiziert 
  • Abklärung einer Disposition für Kardiomyopathien Abklärung einer Disposition für Kardiomyopathien 
  • Abklärung einer Disposition für maligne Herzrhythmusstörungen Abklärung einer Disposition für maligne Herzrhythmusstörungen 
  • Abknickung und Striktur des Ureters ohne Hydronephrose Abknickung und Striktur des Ureters ohne Hydronephrose 
  • Abknickung und Striktur des Ureters ohne Hydronephrose mit Infektion der Niere Abknickung und Striktur des Ureters ohne Hydronephrose mit Infektion der Niere 
  • Ablatio chorioideae Ablatio chorioideae 
  • Abnorme Befunde bei der bildgebenden Diagnostik an sonstigen näher bezeichneten Körperstrukturen Abnorme Befunde bei der bildgebenden Diagnostik an sonstigen näher bezeichneten Körperstrukturen 
  • Abnorme Befunde bei der bildgebenden Diagnostik der Extremitäten Abnorme Befunde bei der bildgebenden Diagnostik der Extremitäten 
  • Abnorme Befunde bei der bildgebenden Diagnostik der Harnorgane Abnorme Befunde bei der bildgebenden Diagnostik der Harnorgane 
  • Abnorme Befunde bei der bildgebenden Diagnostik der Leber und der Gallenwege Abnorme Befunde bei der bildgebenden Diagnostik der Leber und der Gallenwege 
  • Abnorme Befunde bei der bildgebenden Diagnostik der Lunge Abnorme Befunde bei der bildgebenden Diagnostik der Lunge 
  • Abnorme Befunde bei der bildgebenden Diagnostik der Mamma [Brustdrüse] Abnorme Befunde bei der bildgebenden Diagnostik der Mamma [Brustdrüse] 
  • ... +17064 
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  • G1 (Well differentiated) 
  • G2 (Moderately differentiated) 
  • G3 (poorly differentiated) 
  • G4 (Undifferentiated) 
  • Not definable 
  • Low-grade malignancy (G1-G2) 
  • Moderately malignant (G2-G3) 
  • Highly malignant (G3-G4) 
  • Unknown 
  • Does not apply 
  • Borderline 
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/ValueSet/mii-vs-onko-icdo3-morphologie
  • 8822/1 | Abdominale Fibromatose 
  • 8504/2 | Abgekapseltes papilläres Karzinom 
  • 8343/3 | Abgekapseltes papilläres Karzinom 
  • 8504/3 | Abgekapseltes papilläres Karzinom mit Invasion 
  • 8158/3 | ACTH-produzierender Tumor 
  • 9261/3 | Adamantinom der langen Röhrenknochen 
  • 9351/1 | Adamantinöses Kraniopharyngeom 
  • 8210/2 | Adenocarcinoma in situ in adenomatösem Polypen 
  • 8263/2 | Adenocarcinoma in situ in tubulovillösem Adenom 
  • 8261/2 | Adenocarcinoma in situ in villösem Adenom 
  • 8140/2 | Adenocarcinoma in situ o.n.A. 
  • 9013/0 | Adenofibrom o.n.A. 
  • 8200/3 | Adenoid-zystisches Karzinom 
  • 8098/3 | Adenoides Basalzellkarzinom 
  • 8075/3 | Adenoides Plattenepithelkarzinom 
  • 8245/3 | Adenokarzinoidtumor 
  • 8215/3 | Adenokarzinom der Analdrüsen 
  • 8390/3 | Adenokarzinom der Hautanhangsgebilde o.n.A. 
  • 8210/3 | Adenokarzinom in adenomatösem Polypen 
  • 8220/3 | Adenokarzinom in familiärer adenomatöser Polypose [FAP] 
  • 8221/3 | Adenokarzinom in multiplen adenomatösen Polypen 
  • 8263/3 | Adenokarzinom in tubulovillösem Adenom 
  • 8261/3 | Adenokarzinom in villösem Adenom 
  • 8573/3 | Adenokarzinom mit apokriner Metaplasie 
  • 8255/3 | Adenokarzinom mit gemischten Subtypen 
  • ... +1179 
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/ValueSet/mii-vs-onko-icdo3-topographie
  • C76.2 | Abdomen o.n.A. 
  • C24.1 | Ampulla Vateri 
  • C21.1 | Analkanal 
  • C21 | Analkanal und Anus 
  • C76-C80 | Anderer oder mangelhaft bezeichneter Sitz 
  • C16.3 | Antrum ventriculi 
  • C21.0 | Anus o.n.A. 
  • C18.1 | Appendix vermiformis 
  • C30-C39 | Atemwege [Respirationstrakt] und intrathorakale Organe 
  • C39.8 | Atemwege [Respirationstrakt] und intrathorakale Organe, mehrere Bereiche überlappend 
  • C69.9 | Auge o.n.A. 
  • C69 | Auge und Augenanhangsgebilde 
  • C69.8 | Auge und Augenanhangsgebilde, mehrere Teilbereiche überlappend 
  • C69-C72 | Auge, Gehirn und sonstige Teile des Zentralnervensystems 
  • C44.1 | Augenlid 
  • C47.9 | Autonomes Nervensystem o.n.A. 
  • C76.3 | Becken o.n.A. 
  • C41.4 | Beckenknochen, Kreuzbein, Steißbein und zugehörige Gelenke 
  • C77.5 | Beckenlymphknoten 
  • C44.4 | Behaarte Kopfhaut und Haut am Hals 
  • C49 | Bindegewebe, Subkutangewebe und sonstige Weichteile 
  • C49-C49 | Bindegewebe, Subkutangewebe und sonstige Weichteile 
  • C49.1 | Bindegewebe, Subkutangewebe und sonstige Weichteile der oberen Extremität und der Schulter 
  • C49.2 | Bindegewebe, Subkutangewebe und sonstige Weichteile der unteren Extremität und der Hüfte 
  • C49.5 | Bindegewebe, Subkutangewebe und sonstige Weichteile des Beckens 
  • ... +391 
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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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Histologie_ID, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Histologie_EinsendeNr, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=LK_untersucht, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Sentinel_LK_untersucht, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.histologie.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.evidence_classification.v0], code=at0000, itemType=CLUSTER, level=3, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059], code=at0059, itemType=CLUSTER, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059]/items[at0060], code=at0060, itemType=ELEMENT, level=5, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059]/items[at0080], code=at0080, itemType=ELEMENT, level=5, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.evidence_classification.v0]/items[at0059]/items[at0040], code=at0040, itemType=ELEMENT, level=5, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1], code=at0000.1, itemType=CLUSTER, level=3, text=pTNM, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0003.1], code=at0003.1, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0004.1], code=at0004.1, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0005.1], code=at0005.1, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=4, 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=
  • LX 
  • L0 
  • L1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=4, 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=
  • VX 
  • V0 
  • V1 
  • V2 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=4, 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=
  • PnX 
  • Pn0 
  • Pn1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0025.1], code=at0025.1, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0031.1], code=at0031.1, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1], code=at0000, itemType=CLUSTER, level=3, text=cTNM, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=4, 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=
  • LX 
  • L0 
  • L1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=4, 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=
  • VX 
  • V0 
  • V1 
  • V2 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=4, 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=
  • PnX 
  • Pn0 
  • Pn1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0031], code=at0031, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=4, 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1], code=at0000, itemType=CLUSTER, level=3, text=Further tumor classification, description=The archetype 'Additional tumor classification' is used to classify malignant neoplasms according to other tumor classifications, apart from the TNM staging system., 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Name of the classification, description=Specification of the name of the classification. If possible, the coding of the specific classification with a terminology is preferred., 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]/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Variante, description=Any additional description for the corresponding classification., 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]/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Stadium, description=The stage/group/grade of the malignancy based on the classification., 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]/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Datum, description=The date the classification was determined., 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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnosesicherung, description=The level of confidence in the identification of the diagnosis., comment=If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: local_terms
  • Klinisch ohne tumorspezifische Diagnostik (nur körperliche Untersuchung) 
  • Klinisch: Klinische Diagnose vor dem Sterbedatum durchgeführt; schließt diagnostische Techniken, inklusive Röntgen, Endoskopie, weitere bildgebende Verfahren, Ultraschall, exploratorische Chirurgie (Laparatomie, etc.) und Autopsie, ohne mikroskopische Gewebediagnose, ein. 
  • Spezifische Tumormarker 
  • Zytologisch: Untersuchung von Zellen aus primären Lokalisationen inklusive Flüssigkeitsaspirationen mittels Endoskopien oder Nadeln. Schließt mikroskopische Untersuchungen von peripheren Blutausstrichen und Ausstrichen von Beckenkammaspirationen ein. 
  • Histologie einer Metastase. 
  • Veraltet; Besser Verwendung von 7.1, 7.2 oder 7.3 
  • Histologie des Primärtumors: Histologische Untersuchung von Gewebe des Primärtumors einschließlich aller Schnitttechniken und Knochenmarksbiopsien. 
  • Histologie Metastase: Histologische Untersuchung des Gewebes aus einer Metastase 
  • Histologie der Autopsie: Histologische Untersuchung des Gewebes bei einer Autopsie 
  • Zytogenetisch und/oder molekularer Test 
  • Unbekannt 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Fruehere_Tumorerkrankung'], code=at0000, itemType=SECTION, level=1, text=Fruehere_Tumorerkrankung, 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='Fruehere_Tumorerkrankung']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Frühere Tumordiagnose, 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='Fruehere_Tumorerkrankung']/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='Fruehere_Tumorerkrankung']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=ICD, 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= Terminology: http://fhir.de/CodeSystem/bfarm/icd-10-gm
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/bfarm/icd-10-gm
  • Z89.3 | (Teilweiser) Verlust der oberen Extremität, beidseitig 
  • Z89.7 | (Teilweiser) Verlust der unteren Extremität, beidseitig 
  • E25.00 | 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 
  • E25.01 | 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 
  • P55.1 | AB0-Isoimmunisierung beim Fetus und Neugeborenen 
  • T80.3 | AB0-Unverträglichkeitsreaktion 
  • A42.1 | Abdominale Aktinomykose 
  • R19.80 | Abdominales Kompartmentsyndrom 
  • O00.0 | Abdominalgravidität 
  • H35.7 | Abhebung von Netzhautschichten 
  • F60.7 | Abhängige (asthenische) Persönlichkeitsstörung 
  • Z99.0 | Abhängigkeit (langzeitig) vom Aspirator 
  • Z99.1 | Abhängigkeit (langzeitig) vom Respirator 
  • Z99 | Abhängigkeit (langzeitig) von unterstützenden Apparaten, medizinischen Geräten oder Hilfsmitteln, anderenorts nicht klassifiziert 
  • Z01.81 | Abklärung einer Disposition für Kardiomyopathien 
  • Z01.80 | Abklärung einer Disposition für maligne Herzrhythmusstörungen 
  • N13.5 | Abknickung und Striktur des Ureters ohne Hydronephrose 
  • N13.67 | Abknickung und Striktur des Ureters ohne Hydronephrose mit Infektion der Niere 
  • H31.4 | Ablatio chorioideae 
  • R93.8 | Abnorme Befunde bei der bildgebenden Diagnostik an sonstigen näher bezeichneten Körperstrukturen 
  • R93.6 | Abnorme Befunde bei der bildgebenden Diagnostik der Extremitäten 
  • R93.4 | Abnorme Befunde bei der bildgebenden Diagnostik der Harnorgane 
  • R93.2 | Abnorme Befunde bei der bildgebenden Diagnostik der Leber und der Gallenwege 
  • R91 | Abnorme Befunde bei der bildgebenden Diagnostik der Lunge 
  • R92 | Abnorme Befunde bei der bildgebenden Diagnostik der Mamma [Brustdrüse] 
  • ... +17064 
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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=Fernmetastase, 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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