TEMPLATE Radiologischer Befund - Pankreaskarzinom (Radiologischer Befund - Pankreaskarzinom)

TEMPLATE IDRadiologischer Befund - Pankreaskarzinom
ConceptRadiologischer Befund - Pankreaskarzinom
DescriptionZur Repräsentation der Ergebnisse und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen im Rahmen des HiGHmed-Projektes.
UseWird verwendet, um radiologische Befunde von CT und MRT bei Patienten mit Pankreaskarzinom zu berichten.
MisuseNicht zur Repräsentation der klinischen Veränderungen einer Krankheit verwenden.
PurposeZur Repräsentation der Ergebnisse und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen im Rahmen des HiGHmed-Projektes.
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=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=21950bd11b2467f9f52bae812aaad244, build_uid=0c80c276-ecf5-4634-8c81-20008f20ecd3, sem_ver=26.0.0}
KeywordsRadiologischer Befund; Report; Pankreaskarzinom; HiGHmed; UseCase Onkologie; Tumorbildgebung; Tumor-Radiologische Diagnose; Bildgebung; Diagnostik; Bildgebendes Verfahren; Bildgebende Diagnostik; CT; MRT
Language useden
Citeable Identifier1246.169.342
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  • Vorläufig
  • Final
  • Korrigiert
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  • Pankreasuntersuchung
Default value: Pankreasuntersuchung, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0091], code=at0091, itemType=ELEMENT, level=5, text=Modalität, description=The type of imaging device, process or method that originally acquired or produced the data used to create the images in the study., comment=For example: 'XRay', 'CT scan', 'ultrasound', 'MRI', 'bone densitometry', 'tomography', 'mammography', 'nuclear medicine', 'PET', 'angiography', and 'fluoroscopy'. This data element may be redundant if the modality is clearly represented in the 'Study name'. Alternatively it may also be possible to autopopulate the 'Modality' from a coded 'Study name'. Coding of the 'Modality' with a value set is recommended, such as the DICOM CID 29 Acquisition Modality value set. Equivalent to ImagingStudy.modality in FHIR and Modality (0008, 0060) in DICOM., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • CT
  • MR
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  • Initialbefund
  • Nach Neoadjuvanz
  • Nach lokaler Therapie
  • Unter systemischer Therapie
  • Verlaufskontrolle ohne Therapie
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  • Anomaly 
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  • Ja
  • Nein
  • Unklar
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  • Pankreaskopf
  • Proc. uncinatus
  • Pankreaskorpus
  • Pankreasschwanz
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=7, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt TC (truncus coeliacus)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt TC (truncus coeliacus), description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt TC (truncus coeliacus)']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt TC (truncus coeliacus)
Default value: Gefäßkontakt TC (truncus coeliacus), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt TC (truncus coeliacus)']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Gefäßkontakt TC (truncus coeliacus), description=Narrative description of the imaging findings observed during this examination., 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 Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
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  • Gefäßkontakt LA (Leberarterie)
Default value: Gefäßkontakt LA (Leberarterie), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt LA (Leberarterie)']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Gefäßkontakt LA (Leberarterie), description=Narrative description of the imaging findings observed during this examination., 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 Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt LA (Leberarterie)']/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt LA, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt AMS (Arteria mesenterica superior), description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt AMS (Arteria mesenterica superior)
Default value: Gefäßkontakt AMS (Arteria mesenterica superior), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Gefäßkontakt AMS (Arteria mesenterica superior), description=Narrative description of the imaging findings observed during this examination., 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 Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt AMS (Arteria mesenterica superior)']/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt AMS, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt VMS (Vena mesenterica superia), description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt VMS (Vena mesenterica superia)
Default value: Gefäßkontakt VMS (Vena mesenterica superia), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Gefäßkontakt VMS (Vena mesenterica superia), description=Narrative description of the imaging findings observed during this examination., 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 Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt VMS (Vena mesenterica superia)']/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt VMS, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)'], code=at0000, itemType=CLUSTER, level=6, text=Gefäßkontakt PA (inkl. PA-Thrombose), description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Gefäßkontakt PA (inkl. PA-Thrombose)
Default value: Gefäßkontakt PA (inkl. PA-Thrombose), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Gefäßkontakt PA (inkl. PA-Thrombose), description=Narrative description of the imaging findings observed during this examination., 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 Kontakt 
  • Kontakt ≤ 180° 
  • Kontakt > 180° 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Gefäßkontakt PA (inkl. PA-Thrombose)']/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Kommentar zum Gefäßkontakt PA, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Primärtumor Kommentar, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Pfortaderthrombose'], code=at0000, itemType=CLUSTER, level=5, text=Pfortaderthrombose, description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Pfortaderthrombose']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Pfortaderthrombose
Default value: Pfortaderthrombose, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Pfortaderthrombose']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Pfortaderthrombose vorhanden?, description=Narrative description of the imaging findings observed during this examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Ja
  • Nein
  • Unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Pfortaderthrombose']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Pfortaderthrombose Kommentar, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Fernmetastasen'], code=at0000, itemType=CLUSTER, level=5, text=Fernmetastasen, description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Fernmetastasen']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Fernmetastasen
Default value: Fernmetastasen, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Fernmetastasen']/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=6, text=Metastasierungsort, description=A physical site on or within the human body., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Fernmetastasen']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Metastasierungsort, 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_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Lunge (PUL) 
  • Knochen (OSS) 
  • Leber (HEP) 
  • Hirn (BRA) 
  • Lymphknoten (LYM) 
  • Knochenmark (MAR) 
  • Pleura (PLE) 
  • Peritoneum (PER) 
  • Nebenniere (ADR) 
  • Nieren (KID) 
  • Haut (SKI) 
  • Andere Organe (OTH) 
  • Generalisierte Metastasierung (GEN) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Fernmetastasen']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Fernmetastasen vorhanden?, description=Narrative description of the imaging findings observed during this examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Ja
  • Nein
  • Unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Fernmetastasen']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Fernmetastasen Kommentar, description=Additional narrative about the imaging findings of the body structure, 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-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Lokalrezidiv'], code=at0000, itemType=CLUSTER, level=5, text=Lokalrezidiv, description=Findings on radiological examination of a specified body structure or region., 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.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Lokalrezidiv']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Befund, description=Identification of the body structure or region examined., comment=For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Lokalrezidiv
Default value: Lokalrezidiv, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam.v1 and name/value='Lokalrezidiv']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Lokalrezidiv vorhanden?, description=Narrative description of the imaging findings observed during this examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Ja
  • Nein
  • Unklar
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  • PR (partial response) 
  • SD (stable disease) 
  • PD (progressive disease) 
  • CR (complete response) 
  • U (Beurteilung unmöglich) 
  • X (Fehlende Angabe) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=5, text=Verlaufsbeurteilung Gesamtbefund, description=Narrative description about the comparison of this examination with previous similar studies., comment=Also use this data element to indicate if no comparison images and/or reports are available. Details about the images used for comparison can be recorded using the 'Comparison study details' CLUSTER, within Protocol., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Befundkonstanz
  • Befundverbesserung
  • Befundverschlechterung
  • Divergentes Verhalten
  • Beurteilung ist nicht möglich
  • Nicht zutreffend (Initialbefund)
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  • Qualität ausreichend
  • Qualität eingeschränkt
  • Nicht diagnostisch
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  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[at0104], code=at0104, itemType=ELEMENT, level=3, text=Maßnahme-ID, description=Unique identifier for the imaging report assigned by the radiology service., comment=As one instance of this archetype is used per study, this identifier can be used to connect more than one imaging study within a single combined report. Equivalent to DiagnosticReport.identifier in FHIR., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  Text
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  • CT
Default value: CT, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Native Phase'], code=at0014, itemType=ELEMENT, level=4, text=Native Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Native Phase - Ja
  • Native Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Spätarterielle Phase'], code=at0014, itemType=ELEMENT, level=4, text=Spätarterielle Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Spätarterielle Phase - Ja
  • Spätarterielle Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Venöse Phase'], code=at0014, itemType=ELEMENT, level=4, text=Venöse Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Venöse Phase - Ja
  • Venöse Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='CT Bildgebendes Verfahren']/items[at0014 and name/value='Spätvenöse Phase'], code=at0014, itemType=ELEMENT, level=4, text=Spätvenöse Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Spätvenöse Phase - Ja
  • Spätvenöse Phase - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren'], code=at0000, itemType=CLUSTER, level=3, text=MR Verfahren, description=Zur Darstellung 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.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Bezeichnung des technischen Verfahrens, description=Zur Dokumentation des Typs des durchgeführten bildgebenden Verfahrens., comment=z. B. Diffusionswichtung bei MRT, die Art oder Weg der Verabreichung von Kontrastmittel, Radiopharmazeutika und / oder angewendete Behandlung., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • MR
Default value: MR, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial - Ja
  • T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert nativ axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert nativ axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert nativ axial - Ja
  • T1 GRE fettsupprimiert nativ axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert spätarteriell axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert spätarteriell axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert spätarteriell axial - Ja
  • T1 GRE fettsupprimiert spätarteriell axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert venös axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert venös axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert venös axial - Ja
  • T1 GRE fettsupprimiert venös axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert spätvenös axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert spätvenös axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert spätvenös axial - Ja
  • T1 GRE fettsupprimiert spätvenös axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T1 GRE fettsupprimiert hepatobiliär axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fettsupprimiert hepatobiliär axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T1 GRE fettsupprimiert hepatobiliär axial - Ja
  • T1 GRE fettsupprimiert hepatobiliär axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T2 axial'], code=at0014, itemType=ELEMENT, level=4, text=T2 axial, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T2 axial - Ja
  • T2 axial - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='T2 koronar'], code=at0014, itemType=ELEMENT, level=4, text=T2 koronar, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • T2 koronar - Ja
  • T2 koronar - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='Diffusionswichtung b=0-100 s/mm2'], code=at0014, itemType=ELEMENT, level=4, text=Diffusionswichtung b=0-100 s/mm2, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Diffusionswichtung b=0-100 s/mm2 - Ja
  • Diffusionswichtung b=0-100 s/mm2 - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='MR Verfahren']/items[at0014 and name/value='Diffusionswichtung b=500-1000 s/mm2'], code=at0014, itemType=ELEMENT, level=4, text=Diffusionswichtung b=500-1000 s/mm2, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Diffusionswichtung b=500-1000 s/mm2 - Ja
  • Diffusionswichtung b=500-1000 s/mm2 - Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='Kontrastmittel'], code=at0000, itemType=CLUSTER, level=3, text=Kontrastmittel, description=Zur Darstellung 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.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='Kontrastmittel']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Bezeichnung des technischen Verfahrens, description=Zur Dokumentation des Typs des durchgeführten bildgebenden Verfahrens., comment=z. B. Diffusionswichtung bei MRT, die Art oder Weg der Verabreichung von Kontrastmittel, Radiopharmazeutika und / oder angewendete Behandlung., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Kontrastmittel
Default value: Kontrastmittel, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_technique.v1 and name/value='Kontrastmittel']/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=KM Angewendete Parameter, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Nativ
  • Extrazelluläres KM
  • Intrazelluläres KM
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"der Patient lehnte die Verwendung eines Kontrastmittels ab" oder " MRT konnte nicht durchgeführt werden wegen ..."., 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.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.dicom_module_series_metadata.v0], code=at0000, itemType=CLUSTER, level=3, text=DICOM module series metadata, description=DICOM compliant representation of metadata referring to the module series of DICOM., 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.v1]/protocol[at0025]/items[openEHR-EHR-CLUSTER.dicom_module_series_metadata.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=DICOM series instance UID (Serien Kennung), description=Referes to DICOM Tag (0020,000E)., 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-SECTION.problem_list.v0], code=at0000, itemType=SECTION, level=1, text=Tumordiagnose_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], code=at0000, itemType=EVALUATION, level=2, text=Tumordiagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=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]/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]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Diagnose Name (ICD-10), 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]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Diagnose Beschreibung, 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]/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]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0], code=at0000, itemType=CLUSTER, level=4, text=Tumor ID, description=Zur Darstellung der ID des Tumors., 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]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Tumor ID, description=Die ID/Kennung des Tumors., 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]], templateType=normal]