TEMPLATE Lokale interventionelle Therapie (Lokale interventionelle Therapie)

TEMPLATE IDLokale interventionelle Therapie
ConceptLokale interventionelle Therapie
DescriptionZur Repräsentation von Daten zu einer lokalen interventionellen Therapie eines Patienten mit einer onkologischen Diagnose.
UseDieses Template wird verwendet, um Daten zu einer lokalen interventionellen Therapie von Patienten mit einer onkologischen Diagnose zu verzeichnen. Es sollen folgende Daten zu der lokalen interventionellen Therapie wie Art/Methode, Lokalisation, Art der Bildgebung, Therapieergebnis pro therapierte Läsion, Anzahl der erfassten Läsionen, Anzahl der behandelten Läsionen, Grund für das Ende der Therapie, Komplikation, 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 lokalen interventionellen Therapie eines Patienten mit einer onkologischen Diagnose.
References
Authorsdate: 2019-06-26; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de
Other Details Languagedate: 2019-06-26; 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 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=55DB2D45BC470E831EE8C905348471E4, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=bd9b6732e6f08872d0497ffa04b1ef8d}
KeywordsLokale Tumortherapie; lokale interventionelle Therapie; lokale Therapieverfahren; Lokalablative Verfahren; Lokoregionäre Therapieverfahren; Minimal invasive Tumortherapie; Radiologische Intervention
Language useden
Citeable Identifier1246.169.359
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Lokale interventionelle 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=Report ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=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=Lokale interventionelle Therapie, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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=Procedure name, 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_TEXT, bindings=null, values=Default value: Lokale Interventionelle Therapie, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0049], code=at0049, itemType=ELEMENT, level=3, text=Description, description=Narrative description about the procedure, as appropriate for the pathway step., comment=For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure., 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[at0065], code=at0065, itemType=ELEMENT, level=3, text=LIT Art/Methode, 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_CODED_TEXT, bindings=null, values=
  • Radiofrequenzablation  []
  • Laserablation  []
  • Mikrowellenablation  []
  • Irreversible Elektroporation  []
  • Kryoablation  []
  • Hochintensiver fokussierter Ultraschall  []
  • Perkutane Ethanolinjektion  []
  • transarterielle Chemoembolisation  []
  • Drug-Eluting-Bead-TACE  []
  • selektive interne Radiotherapie  []
  • Chemosaturation  []
  • transarterielle Embolisation  []
  • Sonstige Techniken  []
  • Transarterielle Radioembolisation  []
Terminology: local_terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0063], code=at0063, itemType=ELEMENT, level=3, text=Body site, description=Identification of the body site for the procedure., comment=Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Procedure detail' SLOT in this archetype. If the anatomical location 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_CODED_TEXT, bindings=null, values=
  • Lunge  []
  • Knochen  []
  • Leber  []
  • Hirn  []
  • Lymphknoten  []
  • Knochemark  []
  • Pleura  []
  • Peritoneum  []
  • Nebennieren  []
  • Nieren  []
  • Haut  []
  • Andere Organe  []
  • Generalisierte Metastasierung  []
Terminology: lokalisation, 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[at0006], code=at0006, itemType=ELEMENT, level=3, text=Complication, description=Details about any complication arising from the procedure., comment=Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter., 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-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  []
  • Symptomatisch  []
  • lokal kurativ  []
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 zur Therapie, 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.procedure.v1]/protocol[at0053]/items[at0054], code=at0054, itemType=ELEMENT, level=3, text=Lokale interventionelle Therapie ID, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service., comment=This is equivalent to Placer Order Number in HL7 v2 specifications., 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-ACTION.imaging_exam.v0], code=at0000, itemType=ACTION, level=1, text=Imaging examination, description=Clinical activity about performing an imaging examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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.imaging_exam.v0]/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.imaging_exam.v0]/description[at0001]/items[at0017], code=at0017, itemType=ELEMENT, level=3, text=Bildgebende Steuerung, description=The name of the examination (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Sonographie
  • CT
  • MRT
  • DSA
  • [...]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.imaging_exam.v0]/description[at0001]/items[openEHR-EHR-CLUSTER.lesions_details.v1], code=at0000, itemType=CLUSTER, level=3, text=Läsionen Details, description=Zur Darstellung der Anzahl von erfassten und behandelten Läsionen durch eine medizinische Bildgebung innerhalb einer Therapie., comment=Bei Läsionen handelt es sich um morphologisch abnorme Strukturen (morphologische Abnormalitäten)., 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.imaging_exam.v0]/description[at0001]/items[openEHR-EHR-CLUSTER.lesions_details.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Anzahl der erfassten Läsionen, description=Anzahl der Läsionen, die innerhalb einer medizischen Bildgebung im Rahmen einer Therapie erfasst wurden., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.imaging_exam.v0]/description[at0001]/items[openEHR-EHR-CLUSTER.lesions_details.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Anzahl der behandelten Läsionen, description=Anzahl der Läsionen, die im Rahmen einer Therapie behandelt und durch eine medizische Bildgebung erfasst wurden., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.imaging_exam.v0]/description[at0001]/items[openEHR-EHR-CLUSTER.imaging_result.v0], code=at0000, itemType=CLUSTER, level=3, text=Imaging result, description=Imaging result as a single value or as a nested group result., 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-ACTION.imaging_exam.v0]/description[at0001]/items[openEHR-EHR-CLUSTER.imaging_result.v0]/items[at0001], code=at0001, itemType=CLUSTER, level=4, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., comment=null, uncommonOntologyItems=null, occurencesFormal=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.imaging_exam.v0]/description[at0001]/items[openEHR-EHR-CLUSTER.imaging_result.v0]/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Result, description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Ablationsausmaß: 100% + Sicherheitsabstand
  • Ablationsausmaß: 100% ohne Sicherheitsabstand
  • Ablationsausmaß: <100%
  • Dosimetrie: Läsion vollständig erfasst
  • Dosimetrie: Läsion nicht vollständig erfasst
  • Devaskularisation: vollständig
  • Devaskularisation: nicht vollständig
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.imaging_exam.v0]/protocol[at0015], code=at0015, 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]