| All | OperationalTemplate [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=Radiological findings - Hepatocellular carcinoma, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1], code=at0000, itemType=OBSERVATION, level=1, text=Imaging examination result, description=The result of an imaging examination performed on an individual, using radiological techniques., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Study name, description=The name of the imaging examination performed., comment=For example: 'CT abdomen'; 'Doppler ultrasound of renal artery' or 'Plain chest xray'. Coding with a terminology is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Examples of candidate terminologies are the LOINC Imaging Document Codes, RadLex Playbook or SNOMED-CT. Equivalent to DiagnosticReport.code in FHIR., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0091], code=at0091, itemType=ELEMENT, level=5, text=Modality, 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=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.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0070], code=at0070, itemType=ELEMENT, level=5, text=Study date, description=Date/time when the imaging started., comment=Equivalent to ImagingStudy.started in FHIR., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0061], code=at0061, itemType=ELEMENT, level=5, text=Treatment situation, description=Narrative description about the reason the examination was originally requested., comment=Also known as 'Clinical question' or 'Clinical query'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Initial finding
- After neoadjuvant therapy
- After local therapy
- Under systemic therapy
- Follow-up without therapy
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Imaging findings, description=Narrative description or overview of all clinical findings., 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-liver.v0], code=at0000.1, itemType=CLUSTER, level=5, text=Imaging Examination of Target Lesions, description=Findings observed in an imaging examination targeting the liver, using radiographic techniques., 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-liver.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=6, text=Body structure, description=Identification of the body structure or region examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-liver.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Number of target lesions, 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=, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0], code=at0000.1, itemType=CLUSTER, level=6, text=To target lesion, description=A finding on radiological examination that deviates from what is standard, normal or expected within an identified body structure or region., comment=For example: a cyst or mass; a thrombosis; a polyp; a calculus or a foreign body., 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=7, text=Body structure, description=Identification of the body structure or region examined., comment=If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Target-lesion localization, description=Identification of the area of the body under examination., comment=For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' data element, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Liver segment 1
- Liver segment 2
- Liver segment 3
- Liver segment 4
- Liver segment 4a
- Liver segment 4b
- Liver segment 5
- Liver segment 6
- Liver segment 7
- Liver segment 8
, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Description of the lesion, 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=, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.lirads.v1], code=at0000, itemType=CLUSTER, level=7, text=LI-RADS, description=The Liver Imaging Reporting and Data System (LI-RADS®) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver observations in individuals at high risk for hepatocellular carcinoma (HCC)., 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.lirads.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=8, text=LI-RADS algorithm, description=The algorithm used to assess and diagnose liver lesions in a patient at risk of HCC., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- CT/MRI Diagnostic LI-RADS
, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.lirads.v1]/items[at0009], code=at0009, itemType=ELEMENT, level=8, text=Report algorithm LI-RADS, description=The LI-RADS category is a score assigned to a focal lesion. The categories span the spectrum of benign to malignant observations occurring in patients with chronic liver disease at risk for cirrhosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- LR-NC
- LR-TIV
- LR-1
- LR-2
- LR-3
- LR-4
- LR-5
- LR-M
, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.lirads.v1]/items[at0018], code=at0018, itemType=ELEMENT, level=8, text=Therapy response category, description=The categories of therapy response (TR) are used to assess the tumor's response after a locoregional therapy., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- LR-TR Not assessable
- LR-TR nonviable
- LR-TR not clear
- LR-TR vital
, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.lirads.v1]/items[at0040], code=at0040, itemType=ELEMENT, level=8, text=LI-RADS comments, description=Additional information about the report that has not yet been documented elsewhere., 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0], code=at0000.1, itemType=CLUSTER, level=7, text=Residual vitality, description=A finding on radiological examination that deviates from what is standard, normal or expected within an identified body structure or region., comment=For example: a cyst or mass; a thrombosis; a polyp; a calculus or a foreign body., 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=8, text=Body structure, description=Identification of the body structure or region examined., comment=If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=8, text=Residual vitality, 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=, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=8, text=Comment on the residual vitality of the lesion, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0.4], code=at0.4, itemType=ELEMENT, level=8, text=Size of the vital part of the HCC, description=A measured dimension of the anomaly., comment=This data element has unlimited occurrences to allow for measurements in 2 or more axes.
If there is no clear orientation of the anomaly, for example length vs width vs height, use multiple occurrences to allow recording of the length of 2 or more axes without any specific orientation, for example 3 x 4 x 5 mm., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Target-Lesion Comment, 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-liver.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-anomaly.v0]/items[at0.4], code=at0.4, itemType=ELEMENT, level=7, text=Size of the lesion, description=A measured dimension of the anomaly., comment=This data element has unlimited occurrences to allow for measurements in 2 or more axes.
If there is no clear orientation of the anomaly, for example length vs width vs height, use multiple occurrences to allow recording of the length of 2 or more axes without any specific orientation, for example 3 x 4 x 5 mm., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-liver.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Target Lesion Comment, 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='Portal vein thrombosis'], code=at0000, itemType=CLUSTER, level=5, text=Portal vein thrombosis, 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='Portal vein thrombosis']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Body structure, 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=, 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='Portal vein thrombosis']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Existing?, 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=, 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='Portal vein thrombosis']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Portal vein thrombosis comment, 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='Regional lymph node metastases'], code=at0000, itemType=CLUSTER, level=5, text=Regional lymph node metastases, 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='Regional lymph node metastases']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Body structure, 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=, 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='Regional lymph node metastases']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Existing?, 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=, 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='Regional lymph node metastases']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Regional lymph node metastases Comment, 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='Distant metastases'], code=at0000, itemType=CLUSTER, level=5, text=Distant metastases, 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='Distant metastases']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Body structure, 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=, 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='Distant metastases']/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=6, text=Metastasis site, 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='Distant metastases']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Metastasis site, 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- Lung
- Bone
- Liver
- Brain
- Lymph node
- Bone marrow
- Pleura
- Peritoneum
- Adrenal gland
- Kidney
- Skin
- Other organs
- Generalized metastasis
, 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='Distant metastases']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Distant metastases present?, 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=, 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='Distant metastases']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Distant Metastases Comment, 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.response_to_treatment.v1], code=at0000, itemType=CLUSTER, level=5, text=mRECIST, description=Evaluation of the response of a disease to therapy. This helps to assess the success of treatment, e.g. radiation or chemotherapy for a tumor., 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.response_to_treatment.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Overall response, description=Term that describes the response to treatment of a disease., comment=This is an already coded terminology of response to, for example, oncological therapy.
Symptoms can be, for example, CR (complete remission of the disease), PR (partial remission), SD (stable disease) or PD (progression of the disease)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- PR (partial response)
- SD (stable disease)
- PD (progressive disease)
- CR (complete response)
- U (assesment impossible)
- X (missing information)
, 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=Assessment of the overall findings, 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=- Consistency of findings
- Improvement of findings
- Deterioration of findings
- Divergent behavior
- Assessment is not possible
- Not applicable (initial findings)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0063], code=at0063, itemType=ELEMENT, level=5, text=Diagnostic quality, description=Assessment about the quality of the examination., comment=Coding of the imaging quality with a value set is recommended. For example: 'excellent, good, fair, poor, and non-diagnostic'; or 'adequate, suboptimal and inadequate'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Sufficient quality
- Quality limited
- Non-diagnostic
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Overall impression, description=Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate., comment=Also referred to as 'Opinion' or 'Conclusion'. Equivalent to DiagnosticReport.conclusion in FHIR., 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], 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.v1]/protocol[at0025]/items[at0092], code=at0092, itemType=ELEMENT, level=3, text=DICOM study instance UID, description=Unique identifier for the imaging study assigned by the imaging device., comment=Equivalent to Study Instance UID (0020,000D) in DICOM and ImagingStudy.identifier in FHIR., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Identifier Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/protocol[at0025]/items[at0104], code=at0104, itemType=ELEMENT, level=3, text=Report identifier, 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
, 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 Imaging Procedure'], code=at0000, itemType=CLUSTER, level=3, text=CT Imaging Procedure, description=To present the technical specifications of an imaging examination carried out., 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='CT Imaging Procedure']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Name of the technical process, description=To document the type of imaging procedure performed., comment=e.g. B. Diffusion weighting in MRI, the type or route of contrast medium administration, radiopharmaceuticals and/or treatment applied., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=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 Imaging Procedure']/items[at0014 and name/value='Native Phase'], code=at0014, itemType=ELEMENT, level=4, text=Native Phase, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Native phase - Yes
- Native phase - No
, 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 Imaging Procedure']/items[at0014 and name/value='Late arterial phase'], code=at0014, itemType=ELEMENT, level=4, text=Late arterial phase, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Late arterial phase - Yes
- Late Arterial Phase - No
, 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 Imaging Procedure']/items[at0014 and name/value='Venous phase'], code=at0014, itemType=ELEMENT, level=4, text=Venous phase, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Portal Venous Phase - Yes
- Portal Venous Phase - No
, 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 Imaging Procedure']/items[at0014 and name/value='Late venous phase'], code=at0014, itemType=ELEMENT, level=4, text=Late venous phase, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Late venous phase - Yes
- Late venous phase - No
, 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 Procedure'], code=at0000, itemType=CLUSTER, level=3, text=MR Procedure, description=To present the technical specifications of an imaging examination carried out., 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 Procedure']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Name of the technical process, description=To document the type of imaging procedure performed., comment=e.g. B. Diffusion weighting in MRI, the type or route of contrast medium administration, radiopharmaceuticals and/or treatment applied., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=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 Procedure']/items[at0014 and name/value='T1 with chemical shift imaging (in-opp phase /Dixon) axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 with chemical shift imaging (in-opp phase /Dixon) axial, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- T1 with chemical shift imaging (in-opp phase /Dixon) axial - Yes
- T1 with chemical shift imaging (in-opp phase /Dixon) axial - No
, 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 Procedure']/items[at0014 and name/value='T1 GRE grease suppressed native axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE grease suppressed native axial, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- T1 GRE Fat Suppressed Native Axial - Yes
- T1 GRE Grease Suppressed Native Axial - No
, 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 Procedure']/items[at0014 and name/value='T1 GRE fat suppressed late arterial axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fat suppressed late arterial axial, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- T1 GRE fat suppressed late arterial axial - Yes
- T1 GRE fat suppressed late arterial axial - No
, 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 Procedure']/items[at0014 and name/value='T1 GRE fat suppressed venous axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fat suppressed venous axial, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- T1 GRE fat suppressed venous axial - Yes
- T1 GRE fat suppressed venous axial - No
, 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 Procedure']/items[at0014 and name/value='T1 GRE fat-suppressed late venous axial'], code=at0014, itemType=ELEMENT, level=4, text=T1 GRE fat-suppressed late venous axial, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- T1 GRE fat-suppressed late venous axial - Yes
- T1 GRE fat-suppressed late venous axial - No
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- T1 GRE fat-suppressed hepatobiliary axial - No
, 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 Procedure']/items[at0014 and name/value='T2 axial'], code=at0014, itemType=ELEMENT, level=4, text=T2 axial, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, 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 Procedure']/items[at0014 and name/value='T2 coronary'], code=at0014, itemType=ELEMENT, level=4, text=T2 coronary, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, 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 Procedure']/items[at0014 and name/value='Diffusion-weighting b=0-100 s/mm2'], code=at0014, itemType=ELEMENT, level=4, text=Diffusion-weighting b=0-100 s/mm2, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Diffusion-weighting b=0-100 s/mm2 - Yes
- Diffusion-weighting b=0-100 s/mm² - No
, 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 Procedure']/items[at0014 and name/value='Diffusion-weighting b=500-1000 s/mm2'], code=at0014, itemType=ELEMENT, level=4, text=Diffusion-weighting b=500-1000 s/mm2, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Diffusion weighting b=500-1000 s/mm² - Yes
- Diffusion weighting b=500-1000 s/mm² - No
, 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='Contrast medium'], code=at0000, itemType=CLUSTER, level=3, text=Contrast medium, description=To present the technical specifications of an imaging examination carried out., 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='Contrast medium']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Name of the technical process, description=To document the type of imaging procedure performed., comment=e.g. B. Diffusion weighting in MRI, the type or route of contrast medium administration, radiopharmaceuticals and/or treatment applied., 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.imaging_technique.v1 and name/value='Contrast medium']/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=CM Applied Parameters, description=To document the subtype of imaging procedure performed., comment=e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Native
- Extracellular CM
- Liver-specific CM
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For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=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=Diagnosis 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[at0079], code=at0079, itemType=ELEMENT, level=4, text=Variant, description=Specific variant or subtype of the Diagnosis, if relevant., comment=For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/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=To display the ID of the tumor., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Tumor ID, description=The ID/identifier of the tumor., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null]], templateType=normal] |