TEMPLATE Systemische Therapie (Systemische Therapie)

TEMPLATE IDSystemische Therapie
ConceptSystemische Therapie
DescriptionZur Repräsentation von Daten zu einer systemischen Therapie eines Patienten mit einer onkologischen Diagnose im HiGHmed Projekt.
UseDieses Template wird verwendet, um Daten zu einer systemischen Therapie von Patienten mit einer onkologischen Diagnose zu verzeichnen. Es sollen folgende Daten zu der systemischen Therapie wie Therapieart, Protokoll, Substanzen, Relation zur OP und Strahlentherapie, Grund für das Ende der Therapie, Gesamtansprechen, Anmerkungen und Intention erfasst werden.
MisuseDieses Template soll nicht verwendet werden, um den Allgemeinzustand, Nebenerkrankungen und Medikationen, Laborparameter, pathologische Daten (pTNM, Residualstatus, Fernmetastasen oder weitere Klassifikationen), radiologische Daten oder molekularpathologische Daten des Patienten zu verzeichnen. Für diese Daten jeweils das eigene Template hierzu benutzen.
PurposeZur Repräsentation von Daten zu einer systemischen Therapie eines Patienten mit einer onkologischen Diagnose im HiGHmed Projekt.
References
Authorsdate: 2019-12-03; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de
Other Details Languagedate: 2019-12-03; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=55DB2D45BC470E831EE8C905348471E4, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr}
KeywordsSystemische Therapie; Sonstige Therapie; Therapieprotokoll; Chemotherapie; Hormontherapie; Immuntherapie; Knochenmarktransplantation; Wait and See; Active Surveillance; Zielgerichtete Substanzen
Language useden
Citeable Identifier1246.169.351
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Systemische Therapie, 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=Systemische Therapie ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=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]/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=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-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=1, text=Systemische Therapie, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, 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-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Therapieart, description=Identification of the procedure by name., comment=Coding of the specific procedure with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Chemotherapie  []
  • Hormontherapie  []
  • Immun- und Antikörpertherapie  []
  • Knochenmarktransplantation  []
  • Wait and see  []
  • Active Surveillance  []
  • Zielgerichtete Substanzen  []
  • Sonstiges  []
Terminology: local_terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0065], code=at0065, itemType=ELEMENT, level=3, text=Protokoll, description=Identification of specific method or technique for the procedure., comment=Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.relation_to_operation.v1], code=at0000, itemType=CLUSTER, level=3, text=Relation zur OP, description=Zur Darstellung des Bezugs einer Strahlentherapie, systemischen Therapie und/oder sonstigen Therapie zu einer operativen Therapie (OP)., 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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.relation_to_operation.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Stellung zur OP, description=Der Bezug einer Strahlentherapie, einer systemischen Therapie oder einer sonstigen Therapie zu einer operativen Therapie (OP)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Neoadjuvant  [Eine Therapie, die vor einer Operation durchgeführt wird.]
  • Adjuvant  [Eine Therapie, die nach einer Operation durchgeführt wird.]
  • Ohne Bezug zur OP  [Eine Therapie, die keinen Bezug zur Operation hat.]
  • Intraoperativ  [Eine Therapie, die während einer Operation erfolgt.]
  • Alleinige Therapie  [Es werden keine weiteren Therapien durchgeführt.]
  • Sonstiges  [Sonstiger Bezug zu einer Operation.]
  • Unbekannt  [Die Stellung zur Operation ist nicht bekannt.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1], code=at0000, itemType=CLUSTER, level=3, text=Therapieansprechen, description=Bewertung des Ansprechens einer Erkrankung auf die Therapie. Dies hilft dabei, den Erfolg der Behandlung, z.B. einer Strahlen- oder Chemotherapie bei einer Tumorerkrankung zu beurteilen., comment=null, uncommonOntologyItems=null, occurencesFormal=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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Gesamtansprechen, description=Ausdruck, der das Ansprechen auf die Behandlung einer Erkrankung beschreibt., comment=Es handelt sich um eine bereits kodierte Terminologie des Ansprechens auf z.B. eine onkologische Therapie. Ausprägungen können beispielsweise CR (Vollremisson der Erkrankung), PR (Teilremission), SD (Stabile Erkrankung) oder PD (Progression der Erkrankung) sein., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Partial response  []
  • Stabile disease  []
  • Progressive disease  []
  • Complete response  []
  • Mixed response  []
  • Beurteilung unmöglich  []
  • Fehlende Angabe  []
Terminology: ansprechen, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Kommentar, description=Kommentarfeld zum Therapieansprechen., 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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.relation_to_radiotherapy.v1], code=at0000, itemType=CLUSTER, level=3, text=Relation zur Strahlentherapie, description=Zur Darstellung des Bezugs einer systemischen Therapie und/oder sonstigen Therapie zu einer Strahlentherapie., 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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.relation_to_radiotherapy.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Stellung zur Strahlentherapie, description=Der Bezug einer systemischen Therapie oder einer sonstigen Therapie zu einer Strahlentherapie., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Sequenziell davor  [Eine systemische oder sonstige Therapie, die vor einer Strahlentherapie durchgeführt wird.]
  • Sequenziell danach  [Eine systemische oder sonstige Therapie, die nach einer Strahlentherapie durchgeführt wird.]
  • Synchron/simultan  [Eine systemische oder sonstige Therapie, die gleichzeitig während einer Strahlentherapie durchgeführt wird.]
  • Konsolidierend  [Eine systemische oder sonstige Therapie, die extra (zusätzlich) nach einer primären Strahlentherapie durchgeführt wird.]
  • Ohne Bezug  [Eine systemische oder sonstige Therapie, die keinen Bezug zur Strahlentherapie hat.]
  • Alleinige Therapie  [Es werden keine weiteren Therapien, außer dieser systemischen/sonstigen Therapie durchgeführt.]
  • Sonstiges  [Sonstiger Bezug zu einer Strahlentherapie.]
  • Unbekannt  [Die Stellung zur Strahlentherapie ist nicht bekannt.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0048], code=at0048, itemType=ELEMENT, level=3, text=Ende Grund, description=Outcome of procedure performed., comment=Coding with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Abbruch wegen Nebenwirkung/Toxizität  []
  • Reguläres Ende  []
  • Patient verweigert weitere Therapie  []
  • Reguläres Ende mit Dosisreduktion  []
  • Abbruch wegen Progress  []
  • Unbekannt  []
  • Abbruch aus sonstigen Gründen  []
Terminology: ende grund, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Intention, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Kurativ  []
  • Palliativ  []
  • Sonstiges  []
  • Fehlende Angabe  []
Terminology: intention, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Anmerkungen, description=Additional narrative about the activity or care pathway step 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-ACTION.procedure.v1]/protocol[at0053], code=at0053, 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-ACTION.medication.v1], code=at0000, itemType=ACTION, level=1, text=Substanzen, description=Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item., comment=This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, 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-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Substanz, description=Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity., comment=For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available., 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-ACTION.medication.v1]/protocol[at0030], code=at0030, 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]], templateType=normal]