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 andere Therapien oder Prozeduren des Patienten zu verzeichnen. Für diese Daten sind jeweils andere Templates zu 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=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=fda621ca8dd876a186a23e25b4ac61ee, sem_ver=6.1.1}
KeywordsLokale Tumortherapie; lokale interventionelle Therapie; lokale Therapieverfahren; Lokalablative Verfahren; Lokoregionäre Therapieverfahren; Minimal invasive Tumortherapie; Radiologische Intervention
Language useden
Citeable Identifier1246.169.359
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  • Zwischenbericht
  • Endbericht
, 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-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=Lokale Interventionelle Therapie 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=Value set: external, 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=Terminology: lokalisation
  • Lunge 
  • Knochen 
  • Leber 
  • Hirn 
  • Lymphknoten 
  • Knochemark 
  • Pleura 
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  • Nebennieren 
  • Nieren 
  • Haut 
  • Andere Organe 
  • Generalisierte Metastasierung 
  • Unbekannt 
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  • *LR-TR Nicht beurteilbar(en) 
  • *LR-TR Avital(en) 
  • *LR-TR nicht eindeutig(en) 
  • *LR-TR vital(en) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.lirads.v1]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=DV_TEXT, description=*, 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.symptom_sign.v1], code=at0000, itemType=CLUSTER, level=3, text=Nebenwirkungen, description=Reported observation of a physical or mental disturbance in an individual., 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.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, 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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0], code=at0000, itemType=CLUSTER, level=4, text=Common Terminology Criteria for Adverse Events (CTCAE), description=A framework for recording any unfavourable and unintended sign, symptom or disease temporally using the CTCAE terminology., 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.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=System Organ Class (SOC), description=The category of the 'Term' in the MedDRA hierarchy., comment=Identified as a MedDRA primary class - representing an anatomical or physiological system, aetiology or purpose., 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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Term, description=The name of the sign, symptom or disease observed., comment=Identified as a MEDRAterm and corresponding code., 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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Grade, description=The severity of the Adverse event., comment=For each Grade, non-specific comments provide some general guidance about the severity for each grade and are represented within square brackets []. In practice, each grade will be represented by a specific clinical description, appropriate for the selected term and will likely be sourced from an external knowledgebase or resource., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: Grade 1 
  • 2: Grade 2 
  • 3: Grade 3 
  • 4: Grade 4 
  • 5: Grade 5 
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  • Fistel
  • Tumorperforation
  • Arrosionsblutungen
  • [...]
, 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=Value set: external, 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=CHOICE, bindings=null, values=
  •  Text
  •  Identifier
, 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
  • Keine Untersuchung durchgeführt
  • [...]
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  • Morphological abnormality 
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  • Ablationsausmaß: 100% + Sicherheitsabstand
  • Ablationsausmaß: 100% ohne Sicherheitsabstand
  • Ablationsausmaß: <100%
  • Dosimetrie: Läsion vollständig erfasst
  • Dosimetrie: Läsion nicht vollständig erfasst
  • Devaskularisation: vollständig
  • Devaskularisation: nicht vollständig
  • Unbekannt
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