- Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
- Custodian Organisation: openEHR Foundation
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
- MD5-CAM-1.0.1: ee164bf627838e6812245104cd18096a
- Original Language: ISO_639-1::en
- Sem Ver: 5.0.0
- Interim report
- Final report
Coding of the specific procedure with a terminology is preferred, where possible.
Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapiemethode
For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.
- neoadjuvant
- adjuvant
- unrelated to the operation
- intraoperatively
- sole therapy
- others
- unknown
This is an already coded terminology of response to, for example, oncological therapy. Symptoms can be, for example, CR (complete remission of the disease), PR (partial remission), SD (stable disease) or PD (progression of the disease).
Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapieansprechen
This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent.
Terminology: Target area
- liver
- Whole body irradiation
- Unknown
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.
- not applicable
- right lobe of the liver
- left lobe of the liver
- Liver segment 1
- Liver segment 2
- Liver segment 3
- Liver segment 4
- Liver segment 4a
- Liver segment 4b
- Liver segment 5
- Liver segment 6
- Liver segment 7
- Liver segment 8
- right liver lobe (caudal)
- right lobe of the liver (cranial)
- left liver lobe (caudal)
- left lobe of the liver (cranial)
- [...]
- Metabolic therapy
The techniques of irradiation are diverse. If possible, encoding with a terminology is preferred.
Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/applikationsart-nuklearmedizinische-therapie
Example: When specifying radiation dose 3.0 Gy, the value is '3.0'.
0..999.999
The individual dose in radiation therapy is usually recorded in grays (Gy) and less frequently in gigabequerels (GBq). For a radiation dose of '3.0 Gy', the unit for the dose is 'Gy'. For a radiation dose of '2.6 GBq', the unit for the dose is 'GBq'.
- Gy
- GyE
- GBq
- MBq
- kBq
The total dose is composed of several individual doses (fractions). For example: 30.0 Gy can be administered in 10 fractions of 3.0 Gy each.
Example: When indicating radiation dose of 30.0 Gy, the value is '30.0'.
0..999.999
The individual dose in radiation therapy is usually recorded in grays (Gy) and less frequently in gigabequerels (GBq). For a radiation dose of '30.0 Gy', the unit for the dose is 'Gy'. For a radiation dose of '26.0 GBq', the unit for the dose is 'GBq'.
- Gy
- GyE
- GBq
- MBq
- kBq
Symptom name should be coded with a terminology, where possible.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Coding with a terminology is preferred, where possible.
Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapieende-grund
For example: the reason for the cancellation or suspension of the procedure.
Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/intention-der-therapie
This is equivalent to Placer Order Number in HL7 v2 specifications.
Text
Identifier
Intended to be used within the COMPOSITION.problem_list.
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'.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
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.
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.