TEMPLATE Radiologischer Befund - Pankreaskarzinom, Cholangiokarzinom (Radiologischer Befund - Pankreaskarzinom, Cholangiokarzinom)

TEMPLATE IDRadiologischer Befund - Pankreaskarzinom, Cholangiokarzinom
ConceptRadiologischer Befund - Pankreaskarzinom, Cholangiokarzinom
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
Other Details Languagedate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=E3BC8668BB89A4BD43BF551931977A9D, original_language=ISO_639-1::de, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=5b773819d69bfa00bfa01a90a2051b79, build_uid=0c80c276-ecf5-4634-8c81-20008f20ecd3}
Language useden
Citeable Identifier1246.169.342
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=Aurelie Tomczak, Institute of Pathology, University Hospital Heidelberg; Nina Bougatf, University Hospital Heidelberg; Natalia Strauch, Medizinische Hochschule Hannover; Antje Wulff, Medizinische Hochschule Hannover, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Radiologischer Befund - Pankreaskarzinom, Cholangiokarzinom, 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=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]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Registriert
  • Teilweise
  • Vorläufig
  • Final
  • Abgeändert
  • Korrigiert
  • Hinzugefügt
  • Abgebrochen
  • Irrtümlich eingegeben
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  • CT
  • MRT
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  • Pankreas
  • Gallengang
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  • Pankreaskopf
  • Proc. uncinatus
  • Pankreaskorpus
  • Pankreasschwanz
  • Intrahepatisch (mit Angabe des/der Lebersegment(e))
  • Perihilär
  • Distal
  • [...]
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  • nicht anwendbar
  • Lebersegment 1
  • Lebersegment 2
  • Lebersegment 3
  • Lebersegment 4
  • Lebersegment 4a
  • Lebersegment 4b
  • Lebersegment 4a/b
  • Lebersegment 5
  • Lebersegment 6
  • Lebersegment 7
  • Lebersegment 8
  • Lebersegmente 2/3
  • Lebersegmente 7/6
  • Lebersegmente 8/5
  • Lebersegmente 2/4a
  • Lebersegmente 3/4b
  • [...]
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  • Initialbefund
  • nach Neoadjuvanz
  • nach lokaler Therapie
  • unter systemischer Therapie
  • Verlaufskontrolle ohne Therapie
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  • Primärtumor vorhanden
  • kein Primärtumor
  • Primärtumor unklar
  • Lokalrezidiv vorhanden
  • kein Lokalrezidiv
  • Lokalrezidiv unklar
  • Fernmetastasen vorhanden
  • keine Fernmetastasen
  • Fernmetastasen unklar
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  • PUL
  • OSS
  • HEP
  • BRA
  • LYM
  • MAR
  • PLE
  • PER
  • ADR
  • KID
  • SKI
  • OTH
  • NULL
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  • TC (truncus coeliacus) - kein Kontakt
  • TC (truncus coeliacus) - Kontakt ≤ 180°
  • TC (truncus coeliacus) - Kontakt > 180°
  • LA (Leberarterie) - kein Kontakt
  • LA (Leberarterie) - Kontakt ≤ 180°
  • LA (Leberarterie) - Kontakt > 180°
  • AMS (Arteria mesenterica superior) - kein Kontakt
  • AMS (Arteria mesenterica superior) - Kontakt ≤ 180°
  • AMS (Arteria mesenterica superior) - Kontakt > 180°
  • VMS (Vena mesenterica superia) - kein Kontakt
  • VMS (Vena mesenterica superia) - Kontakt ≤ 180°
  • VMS (Vena mesenterica superia) - Kontakt > 180°
  • PA (inkl. PA-Thrombose) - kein Kontakt
  • PA (inkl. PA-Thrombose) - Kontakt ≤ 180°
  • PA (inkl. PA-Thrombose) - Kontakt > 180°
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt']/items[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Gefäßkontakt Kommentar, description=Additional information about the result not captured in the Result field., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose'], code=at0000, itemType=CLUSTER, level=5, text=Pfortaderthrombose, description=Imaging result as a single value or as a nested group result., 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]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Pfortaderthrombose, description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Pfortaderthrombose
  • keine Pfortaderthrombose
  • Pfortaderthrombose unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose']/items[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Pfortaderthrombose Kommentar, description=Additional information about the result not captured in the Result field., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1], code=at0000, itemType=CLUSTER, level=5, text=Verlaufsbeurteilung der Bildgebung, description=Beurteilung des Verlaufs des radiologischen Musters für ein bestimmtes Problem oder eine Diagnose eines Patienten zu einem bestimmten Zeitpunkt in der Relation zum einem der vorausgegangenen bildgebenden Untersuchungsergebnissen., comment=Zum Beispiel die Veränderungen der Größe eines diagnostizierten Primärtumors werden in einer Verlaufskontrolle im Vergleich zu dem Initialbefund beurteilt., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Beurteilung der Änderung, description=Die Änderung erfolgte im radiologischen Bild im Vergleich zum vorherigen Bild., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Befundkonstanz  [*]
  • Befundverbesserung  [*]
  • Befundverschlechterung  [*]
  • Beurteilung ist nicht möglich  [z.B. aufgrund fehlender Angaben.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Beschreibung der Änderung, description=Wenn weitere Details zu melden sind, stellt dies eine kurze Beschreibung des geänderten radiologischen Musters oder Kommentare dar., comment=z.B. Bildung von Metastasen, oder Tumorvergrößerung oder Bildung einer Pfortaderthrombose etc., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1], code=at0000, itemType=CLUSTER, level=5, text=Beurteilung des Therapieansprechens, description=Bewertung des Ansprechens einer Erkrankung auf die Therapie. Dies hilft dabei, den Erfolg der Behandlung, z.B. einer Strahlen- oder Chemotherapie bei einer Tumorerkrankung zu beurteilen., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=RECIST 1.1, description=Ausdruck, der das Ansprechen auf die Behandlung einer Erkrankung beschreibt., comment=Es handelt sich um eine bereits kodierte Terminologie des Ansprechens auf z.B. eine onkologische Therapie. Ausprägungen können beispielsweise CR (Vollremisson der Erkrankung), PR (Teilremission), SD (Stabile Erkrankung) oder PD (Progression der Erkrankung) sein., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • PR (partial response)  []
  • SD (stable disease)  []
  • PD (progressive disease)  []
  • CR (Complete response)  []
  • U (Beurteilung unmöglich)  []
  • X (Fehlende Angabe)  []
Terminology: local_terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=5, text=Comparison with previous, description=Narrative descripition about the comparison of this image, or series of images, with previous similar examinations., comment=If there is no availability of previous imaging and/or reports this should also be stated using 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0058], code=at0058, itemType=ELEMENT, level=5, text=Imaging differential diagnosis, description=Single word, phrase or brief description representing a possible condition or diagnosis., comment=This data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0059], code=at0059, itemType=ELEMENT, level=5, text=Recommendation, description=Suggestion for further imaging, investigations and/or referral, and associated rationale., comment=This data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request., 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, 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.imaging_exam_result.v0]/data[at0001]/events[at0002]/state[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=5, text=Diagnostische Qualität, description=Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ausreichend
  • eingeschränkt
  • nicht diagnostisch
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025], code=at0025, 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.imaging_exam_result.v0]/protocol[at0025]/items[at0049], code=at0049, itemType=ELEMENT, level=3, text=Technique, description=Narrative description about the technical details and procedure., comment=For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media., 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.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0], code=at0000, itemType=CLUSTER, level=3, text=Bildgebendes Verfahren, description=Zur Darstellung der der technischen Spezifikationen einer durchgeführten bildgebenden Untersuchung., 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.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0001 and name/value='CT - Native Phase'], code=at0001, itemType=ELEMENT, level=4, text=CT - Native Phase, description=zur Dokumentation des Typs des durchgeführten CT., comment=z. B. Native Phase, Spätarterielle Phase, Venöse Phase, Spätvenöse Phase, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0001 and name/value='CT - Spätarterielle Phase'], code=at0001, itemType=ELEMENT, level=4, text=CT - Spätarterielle Phase, description=zur Dokumentation des Typs des durchgeführten CT., comment=z. B. Native Phase, Spätarterielle Phase, Venöse Phase, Spätvenöse Phase, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0001 and name/value='CT - Venöse Phase'], code=at0001, itemType=ELEMENT, level=4, text=CT - Venöse Phase, description=zur Dokumentation des Typs des durchgeführten CT., comment=z. B. Native Phase, Spätarterielle Phase, Venöse Phase, Spätvenöse Phase, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0001 and name/value='CT - Spätvenöse Phase'], code=at0001, itemType=ELEMENT, level=4, text=CT - Spätvenöse Phase, description=zur Dokumentation des Typs des durchgeführten CT., comment=z. B. Native Phase, Spätarterielle Phase, Venöse Phase, Spätvenöse Phase, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T1 GRE fettsupprimiert nativ axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T1 GRE fettsupprimiert nativ axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T1 GRE fettsupprimiert spätarteriell axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T1 GRE fettsupprimiert spätarteriell axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T1 GRE fettsupprimiert venös axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T1 GRE fettsupprimiert venös axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T1 GRE fettsupprimiert spätvenös axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T1 GRE fettsupprimiert spätvenös axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T1 GRE fettsupprimiert hepatobiliär axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T1 GRE fettsupprimiert hepatobiliär axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T2 axial'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T2 axial, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - T2 koronar'], code=at0007, itemType=ELEMENT, level=4, text=MRT - T2 koronar, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - Diffusionswichtung b=0-100 s/mm2'], code=at0007, itemType=ELEMENT, level=4, text=MRT - Diffusionswichtung b=0-100 s/mm2, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0007 and name/value='MRT - Diffusionswichtung b=500-1000 s/mm2'], code=at0007, itemType=ELEMENT, level=4, text=MRT - Diffusionswichtung b=500-1000 s/mm2, description=zur Dokumentation des Typs des durchgeführten MRT., comment=z. B. T1 GRE fettsupprimiert spätvenös axial, T2 axial, T2 koronar, Diffusionswichtung b=0-100 s/mm2, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ja  [*]
  • Nein  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v0]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Kontrastmittel, description=das Kontrastmittel, das bei der Bildgebung verwendet wurde., comment=z.B. nativ, extrazelluläres KM, intrazelluläres KM, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • nativ
  • extrazelluläres KM
  • intrazelluläres KM
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0057], code=at0057, itemType=ELEMENT, level=3, text=Imaging quality, description=Narrative description about the quality of the examination., comment=For example: the nature of any limitations and their impact on interpretation., 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.imaging_exam_result.v0]/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Details zur Bildstudie (DICOM Studie), description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., 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.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Maßnahmen-ID, description=The local identifier given to the imaging examination report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=4, text=Details zur Bildserie (DICOM Serie), description=Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images., 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.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=5, text=DICOM series identifier, description=Unique identifier of this series allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=5, text=Image DateTime, description=Specific date/time the imaging examination 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]], templateType=normal]