All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=Katrin Tröltzsch, Heidelberg University Hospital, Germany, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Histopathological findings, 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[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1], code=at0000, itemType=OBSERVATION, level=1, text=Histopathological report, description=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., 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.laboratory_test_result.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.laboratory_test_result.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.laboratory_test_result.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.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Pathologisch-anatomische Begutachtung mit kritischer Stellungnahme, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1], code=at0000, itemType=CLUSTER, level=5, text=Specimen, description=A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis., comment=For example: Tissue or body fluid., 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-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=Specimen type, description=The type of specimen., comment=For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible., uncommonOntologyItems={fhir_mapping=Specimen.type}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Laboratory specimen identifier, description=A unique identifier of the specimen, normally assigned by the laboratory., comment=Sometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype., uncommonOntologyItems={fhir_mapping=Specimen.accessionIdentifier}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Identifier Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0088], code=at0088, itemType=ELEMENT, level=6, text=External identifier, description=A unique identifier of the specimen, assigned by a party external to the laboratory., comment=For example: 'Requester ID', 'Archive ID, 'Biobank ID'., uncommonOntologyItems={fhir_mapping=Specimen.identifier}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Identifier Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0073], code=at0073, itemType=ELEMENT, level=5, text=Overall test status, description=The status of the laboratory test result as a whole., comment=The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Coded Text- Registered
- Partial
- Preliminary
- Final
- Amended
- Corrected
- Appended
- Cancelled
- Entered in error
Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0075], code=at0075, itemType=ELEMENT, level=5, text=Initial date of the histological findings (histology date), description=The date and/or time that ‘Overall test status’ was issued., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0077], code=at0077, itemType=ELEMENT, level=5, text=Diagnostic service category, description=The diagnostic service or discipline that is responsible for the laboratory test result., comment=This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0100], code=at0100, itemType=ELEMENT, level=5, text=Clinical information provided, description=Description of clinical information available at the time of interpretation of results., comment=This data element may include a link to the original clinical information provided in the test request., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0], code=at0000, itemType=CLUSTER, level=5, text=Anatomical pathology examination, description=Findings and interpretation of an anatomical pathology examination performed on tissues and body fluids., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0019], code=at0019, itemType=ELEMENT, level=6, text=Examination type, description=Identification of the type of anatomical pathology examination performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Coded Text- Macroscopic examination
- Microscopic examination
Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005], code=at0005, itemType=CLUSTER, level=6, text=Anatomical pathology finding, description=Details of an individual anatomical pathology finding, often related to a specific anatomical location or specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[at0023], code=at0023, itemType=ELEMENT, level=7, text=Finding label, description=A text label for the specific finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Finding description, description=A narrative description of the anatomical pathology finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=7, text=Pathology interpretation, description=Single word, phrase of brief description representing the interpretation of the anatomical pathology finding. A coded term is preferred., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0005]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Tissue available, description=True if the tissue is available for examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Untersuchungsbefund / Diagnosefreitext, description=A narrative description of the entire anatomical pathology examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0], code=at0000, itemType=CLUSTER, level=5, text=Surgical resection margins, description=Details of tumour involvement at margins of surgical resections/biopsies., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0018], code=at0018, itemType=ELEMENT, level=6, text=Margin name, description=The name of the margin being described., comment=For example: 'closest margin', 'circumferential margin', 'deep margin', 'vascular margin' or 'bronchial margin'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Marginal involvement, description=Evidence of tumour at a surgical resection margin., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Equivocal
- Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0006], code=at0006, itemType=CLUSTER, level=6, text=Tumour present, description=Details where tumour is present at the surgical resection margin., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0006]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Maximum linear involvement, description=When tumour is present at surgical resection margin, the maximal length of involvement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0006]/items[at0020], code=at0020, itemType=ELEMENT, level=7, text=Nature of involvement, description=The nature of involvement of the tumour with the surgical margin., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0008], code=at0008, itemType=CLUSTER, level=6, text=Tumour absent, description=Details where tumour is absent from surgical resection margins., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=7, text=Distance from resection margin, description=When tumour is absent, the distance from tumour to the named surgical resection margin., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0008]/items[at0021], code=at0021, itemType=ELEMENT, level=7, text=Tumour name, description=Name of the tumour for which the 'Distance from resection margin' applies., comment=For example: 'Invasive tumour' or 'Cancer in situ'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tumour_resection_margins.v0]/items[at0010], code=at0010, itemType=ELEMENT, level=6, text=Description, description=A text description of tumour involvement at the surgical resection margin., 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- kein Residualtumor (R0)
- Mikroskopischer Residualtumor (R1)
- in-Situ-Rest (R1(is))
- Zytologischer Rest (R1(cy+))
- Makroskopischer Residualtumor (R2)
- Vorhandensein von Residualtumor kann nicht beurteilt werden (RX)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0], code=at0000, itemType=CLUSTER, level=5, text=Lymph node metastases, description=To record findings of tumour metastases in lymph nodes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0041], code=at0041, itemType=ELEMENT, level=6, text=Lymph node site name, description=The name for the lymph node site being reported., comment=This may be a general location e.g. 'Axillary nodes', a relative site e.g. 'Sentinel nodes', 'Apical node', 'Regional nodes' or a individual node., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0044], code=at0044, itemType=ELEMENT, level=6, text=Tissue available, description=Has the appropriate lymph node tissue been made available for examination?, comment=null, 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-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Tumour involvement, description=Findings of lymph node involvement with tumour., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Equivocal
- Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Nature of involvement, description=Nature or grade of the tumour, if present., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Focal
- Diffuse
- Complete
- Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0046], code=at0046, itemType=ELEMENT, level=6, text=Route of involvement, description=The route by which the tumour became involved in lymph node tissue., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Number of nodes examined, description=Number of nodes examined., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Number of nodes with tumour, description=Number of nodes which show tumour involvement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=6, text=Extent of tumour, description=Extent of tumour expressed as a maximum length. Applies only to an individual node., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0039], code=at0039, itemType=CLUSTER, level=6, text=Extra-nodal extension, description=Findings related to extension of tumour external to the nodal capsule., 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-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0039]/items[at0034], code=at0034, itemType=ELEMENT, level=7, text=Extra-capsular extension, description=Findings of extension of tumour beyond a node capsule., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Equivocal
- Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0039]/items[at0014], code=at0014, itemType=ELEMENT, level=7, text=Extent of extranodal tumour, description=Extent of extranodal tumour expressed as a maximum length., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0040], code=at0040, itemType=ELEMENT, level=6, text=Description, description=A text description of lymph node involvement by tumour., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0051], code=at0051, itemType=ELEMENT, level=6, text=Marker dye uptake, description=Findings of whether marker dye has been taken up by the lymph node or lymph node group., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.lymph_node_metastases.v0]/items[at0052], code=at0052, itemType=ELEMENT, level=6, text=Radioactivity count, description=Radioactivity count measured after use of radiocolloid., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0 Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.histology_grading.v1], code=at0000, itemType=CLUSTER, level=5, text=Histology grading, description=The degree of differentiation of the tumor cells is assessed histologically., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.histology_grading.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Histologie Grading (nach WHO), description=Histological degree of differentiation of the tumor cells., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- G1 (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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=5, text=Conclusion, description=Narrative description of the key findings., comment=For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0098], code=at0098, itemType=ELEMENT, level=5, text=Test diagnosis, description=Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result., comment=For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the test result not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0068], code=at0068, itemType=ELEMENT, level=3, text=Laboratory internal identifier, description=A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process., comment=This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Identifier Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=3, text=Test request details, description=Details about the test request., comment=In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0106], code=at0106, itemType=ELEMENT, level=4, text=Original test requested name, description=Name of the original laboratory test requested., comment=This data element is to be used when the test requested differs from the test actually performed by the laboratory., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0062], code=at0062, itemType=ELEMENT, level=4, text=Requester order identifier, description=The local identifier assigned by the requesting clinical system., comment=Equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Identifier Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Receiver order identifier, description=The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS)., comment=Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Identifier Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0], code=at0000, itemType=SECTION, level=1, text=Tumor diagnosis section, description=Framework for consistent modelling of content within a template for a Problem list., comment=Intended to be used within the COMPOSITION.problem_list., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis'], code=at0000, itemType=EVALUATION, level=2, text=Tumor 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=null, occurencesText=null, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0], code=at0000, itemType=CLUSTER, level=4, text=Tumor classification ICD-O, description=International Classification of Diseases for Oncology.
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.
The morphological code describes the cell type of the neoplasm and its biological behaviour. It thus characterises the neoplasm itself., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Morphological Code ICD-O, description=To record the type of cell that has become neoplastic and its biologic activity with the morphology code according to the International classification of diseases for oncology (ICD-O)., comment=There are three parts to a complete morphology code:
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. The grade, differentiation, or phenotype code provides supplementary information about the tumor., 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Morphology description, description=To record the term (narrative description/synonyms) of the morphology code according to the International classification of diseases for oncology (ICD-O)., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=Topography Code ICD-O, description=The topographical describes the site of the neoplasm., comment=In general, it uses the same three- or four-character codes as used in ICD-10 for malignant neoplasms., 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Topography description, description=To record the term (narrative description/synonyms) of the topography code according to the "International classification of diseases for oncology (ICD-O-3)"., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- 0
- 1
- 1a
- 1a1
- 1a2
- 1b
- 1b1
- 1b2
- 1c
- 1c1
- 1c2
- 1c3
- 1d
- 1mic
- 2
- 2a
- 2a1
- 2a2
- 2b
- 2c
- 2d
- 3
- 3a
- 3b
- 3c
- 3d
- 3e
- 4
- 4a
- 4b
- 4c
- 4d
- 4e
- a
- is
- is(DCIS)
- is(LAMN)
- is(LCIS)
- is(Paget)
- is(pd)
- is(pu)
- X
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- 0(i+)
- 0(i-)
- 0(i-)(sn)
- 0(mol+)
- 0(mol-)
- 1
- 1a
- 1a(sn)
- 1b
- 1b a)
- 1b b)
- 1b c)
- 1b d)
- 1c
- 1mi
- 2
- 2a
- 2b
- 2c
- 3
- 3a
- 3b
- 3c
- 4
- X
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- 0
- 1
- 1a
- 1b
- 1bi
- 1bii
- 1biii
- 1biv
- 1c
- 1d
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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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=5, text=Carcinoma in situ (is), description=Record as True if presence of carcinoma in situ associated with the primary tumour., comment=Represented by the prefix 'is' 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0030], code=at0030, itemType=ELEMENT, level=5, text=TNM assessment, description=Concatenation of 'T', 'N' and 'M' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- 0
- 0a
- 0is
- I
- IA
- IA1
- IA2
- IA3
- IB
- IS
- II
- IIA
- IIB
- IIC
- III
- IIIA
- IIIB
- IIIC
- IIID
- IV
- IVA
- IVB
- IVC
- kein Stadtium ermittelbar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- Auflage 8
- Auflage 7
- Auflage 6
- Auflage 5
- Auflage 4
- Auflage 3
- Auflage 2
- Auflage 1
Default value: Auflage 8, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- 0
- 1
- 1a
- 1a1
- 1a2
- 1b
- 1b1
- 1b2
- 1c
- 1c1
- 1c2
- 1c3
- 1d
- 1mic
- 2
- 2a
- 2a1
- 2a2
- 2b
- 2c
- 2d
- 3
- 3a
- 3b
- 3c
- 3d
- 3e
- 4
- 4a
- 4b
- 4c
- 4d
- 4e
- a
- is
- is(DCIS)
- is(LAMN)
- is(LCIS)
- is(Paget)
- is(pd)
- is(pu)
- X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- 0
- 0(i+)
- 0(i-)
- 0(i-)(sn)
- 0(mol+)
- 0(mol-)
- 1
- 1a
- 1a(sn)
- 1b
- 1b a)
- 1b b)
- 1b c)
- 1b d)
- 1c
- 1mi
- 2
- 2a
- 2b
- 2c
- 3
- 3a
- 3b
- 3c
- 4
- X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- X
- 0
- 1
- 1a
- 1b
- 1bi
- 1bii
- 1biii
- 1biv
- 1c
- 1d
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Histopathological grade (G), description=Histopathological grading of the tumour., comment=Pretreatment histopathological assessment may be determined from a limited biopsy prior to formal resection. Coding with a G code appropriate for the identified tumour type and anatomical site is expected. For example: 'G2'; 'GX'; or 'low grade' for bone and soft tissue sarcoma classification. Represented as 'G' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 1
- 2
- 3
- 4
- Degree of differentiation cannot be determined
- Low grade malignant
- Moderately malignant
- Highly malignant
- Does not apply
- Borderline
- Unknown
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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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=5, text=Carcinoma in situ (is), description=Record as True if presence of carcinoma in situ associated with the primary tumour., comment=Represented by the prefix 'is' 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0030.1], code=at0030.1, itemType=ELEMENT, level=5, text=pTNM assessment, description=Concatenation of 'pT', 'pN' and 'pM' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/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=- 0
- 0a
- 0is
- I
- IA
- IA1
- IA2
- IA3
- IB
- IS
- II
- IIA
- IIB
- IIC
- III
- IIIA
- IIIB
- IIIC
- IIID
- IV
- IVA
- IVB
- IVC
- kein Stadium ermittelbar
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- Edition 7
- Edition 6
- Edition 5
- Edition 4
- Edition 3
- Edition 2
- Edition 1
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- clinical
- specific tumor markers
- cytological
- histology of a metastasis
- histological
- unknown
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- exclusively clinical diagnosis
- palpation
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- CT
- PET
- PET-CT
- PET-MRI
- SPECT
- other nuclear medcial imaging
- Ultrasound
- X-ray diagnostics
- Other imaging procedures
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0108]/items[at0116], code=at0116, itemType=ELEMENT, level=7, text=Date/time of the procedure, description=The time and date when the procedure was performed, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0117], code=at0117, itemType=CLUSTER, level=6, text=Microscopic, description=The diagnostic certainty is based on microscopic identification of the tumor., comment=null, uncommonOntologyItems=null, occurencesFormal=0..6, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0117]/items[at0118], code=at0118, itemType=ELEMENT, level=7, text=Microscopic procedure, description=The diagnostic certainty is based on microscopic identification of the tumor., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- histological
- immunophenotyping
- microscopic confirmation with unknown method
- laboratory test or laboratory marker
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0117]/items[at0127], code=at0127, itemType=ELEMENT, level=7, text=Date/Time of the procedure, description=The time and date when the procedure was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0125], code=at0125, itemType=CLUSTER, level=6, text=Other procedures, description=The diagnostic certainty is based on an alternative method not represented in the previous elements., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0125]/items[at0126], code=at0126, itemType=ELEMENT, level=7, text=Other procedures, description=The diagnostic certainty is based on an alternative method not represented in the previous elements., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text Coded Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0125]/items[at0128], code=at0128, itemType=ELEMENT, level=7, text=Date/time of the procedure, description=The time and date when the procedure was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0129], code=at0129, itemType=ELEMENT, level=6, text=Comment, description=Additional information about the collection of diagnostic confirmation., comment=For example, comments about the quality of diagnostic confirmation can be recorded in this data element., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1], code=at0000, itemType=CLUSTER, level=4, 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=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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Description of stage/group/grade, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Stage/Group/Grade, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Date of classification, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Edition of the classification, description=The edition on which the classification used for the assessment is based., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Comment, description=Further description of the additional tumour classification that was not recorded in other areas., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumour_focality.v0], code=at0000, itemType=CLUSTER, level=4, text=Tumor focality, description=Describes the focality or focus of the tumor in a cancer patient., comment=The focus refers to the focus or scattered focus in the sense of a local disease process that can trigger pathological long-distance effects beyond the immediate surroundings., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumour_focality.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Focality, description=Focality of the tumor., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Unifocal
- Bifocal
- Multifokal
- Unknown/inadequately described
- Systemic
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.tumour_focality.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Description of focality, description=Description of the tumor focus., comment=For example, ‘Diffuse growing’, ‘Multicentric breast carcinoma with 3 foci’ or ‘Detection of tumour cells in cerebrospinal fluid sediment’., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=4, text=Anatomical location, description=A physical site on or within the human body., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail.
This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available.
If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Left (L)
- Right (R)
- Bilateral (B)
- Midline/ Central (M)
- Unknown (U)
- Not applicable (T; Side specification not meaningful, including systemic diseases)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=4, text=Comment tumor diagnosis, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/protocol[at0032], code=at0032, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=4, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0], code=at0000, itemType=CLUSTER, level=4, text=Tumor ID, description=To display the ID of the tumor., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumor diagnosis']/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Tumor ID, description=The ID/identifier of the tumor., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase'], code=at0000, itemType=EVALUATION, level=2, text=Fernmetastase, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Distant metastasis, 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: local_terms- No distant metastases
- Distant metastasis
Default value: Keine Fernmetastasen, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Distant metastasis location, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Lung (PUL)
- Bone (OSS)
- Liver (HEP)
- Brain (BRA)
- Lymph nodes (LYM)
- Bone marrow (MAR)
- Pleura (PLE)
- Peritoneum (PER)
- Adrenal gland (ADR)
- Kidneys (KID)
- Skin (SKI)
- Other organs (OTH)
- Generalized metastasis (GEN)
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