TEMPLATE Radiologische Befunde - Hepatozelluläres Karzinom (Radiologische Befunde - Hepatozelluläres Karzinom)

TEMPLATE IDRadiologische Befunde - Hepatozelluläres Karzinom
ConceptRadiologische Befunde - Hepatozelluläres Karzinom
DescriptionZur Erfassungen von Ergebnissen und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen, die bei einem Patienten mit Hepatozellulärem Karzinom durchgeführt wurden.
PurposeZur Erfassungen von Ergebnissen und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen, die bei einem Patienten mit Hepatozellulärem Karzinom durchgeführt wurden.
References
Authorsdate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
Other Details Languagedate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=55DB2D45BC470E831EE8C905348471E4, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=aa2058f99bfa6a8af5e8f9f665b9a0b9, build_uid=5b4193bc-2b9b-43fb-9506-42f061ab3728}
KeywordsHepatozelluläres Karzinom; HCC; Bildgebung; Diagnostik; Bildgebendes Verfahren; Bildgebende Diagnostik; bildgebend; Untersuchung; Ergebnis; Untersuchungsergebnis
Language useden
Citeable Identifier1246.169.401
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  • CT
  • MRT
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  • nativ
  • extrazelluläres KM
  • intrazelluläres KM
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  • Leber
Default value: Leber, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=6, text=Tumorlokalisation HCCs, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Lebersegment 1
  • Lebersegment 2
  • Lebersegment 3
  • Lebersegment 4
  • Lebersegment 5
  • Lebersegment 6
  • Lebersegment 7
  • Lebersegment 8
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  • Initialbefund
  • nach Neoadjuvanz
  • nach lokaler Therapie
  • unter systemischer Therapie
  • Verlaufskontrolle ohne Therapie
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  • regionären Lymphknotenmetastasen vorhanden
  • keine regionären Lymphknotenmetastasen
  • regionären Lymphknotenmetastasen unklar
  • Fernmetastasen vorhanden
  • keine Fernmetastasen
  • Fernmetastasen unklar
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  • PUL
  • OSS
  • HEP
  • BRA
  • LYM
  • MAR
  • PLE
  • PER
  • ADR
  • SKI
  • OTH
  • missing
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  • Pfortaderthrombose vorhanden
  • keine Pfortaderthrombose vorhanden
  • Pfortaderthrombose unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Restaktivität'], code=at0000, itemType=CLUSTER, level=5, text=Restaktivität, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Restaktivität']/items[at0001], code=at0001, itemType=CLUSTER, level=6, 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=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]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Restaktivität']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Restaktivität, 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=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Restaktivität vorhanden
  • kein Restaktivität
  • Restaktivität unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1], code=at0000, itemType=CLUSTER, level=5, text=Verlaufsbeurteilung der Bildgebung, description=Beurteilung des Verlaufs des radiologischen Musters für ein bestimmtes Problem oder eine Diagnose eines Patienten zu einem bestimmten Zeitpunkt in der Relation zum einem der vorausgegangenen bildgebenden Untersuchungsergebnissen., comment=Zum Beispiel die Veränderungen der Größe eines diagnostizierten Primärtumors werden in einer Verlaufskontrolle im Vergleich zu dem Initialbefund beurteilt., 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.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Beurteilung der Änderung, description=Die Änderung erfolgte im radiologischen Bild im Vergleich zum vorherigen Bild., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Befundkonstanz  [*]
  • Befundverbesserung  [*]
  • Befundverschlechterung  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Beschreibung der Änderung, description=Wenn weitere Details zu melden sind, stellt dies eine kurze Beschreibung des geänderten radiologischen Musters oder Kommentare dar., comment=z.B. Bildung von Metastasen, oder Tumorvergrößerung oder Bildung einer Pfortaderthrombose etc., 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.v0]/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, 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.v0]/data[at0001]/events[at0002]/state[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=5, text=Diagnostische Qualität, description=Narrative description of factors, not recorded elsewhere, that may influence the test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Qualität ausreichend
  • Qualität eingeschränkt
  • nicht diagnostisch
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/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.v0]/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Details zur Bildstudie (DICOM Studie), description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., 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.v0]/protocol[at0025]/items[at0027]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Maßnahmen-ID, description=The local identifier given to the imaging examination report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=4, text=Details zur Bildserie (DICOM Serie), description=Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images., 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.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=5, text=DICOM series identifier, description=Unique identifier of this series allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=5, text=Image DateTime, description=Specific date/time the imaging examination was performed., comment=null, 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.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging.v0], code=at0000, itemType=CLUSTER, level=3, text=Imaging details, description=Details of imaging, used in requests for imaging, records of imaging procedures and imaging reports., 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.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Imaging category, description=The type of imaging., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Native Phase
  • Spätarterielle Phase
  • Venöse Phase
  • Spätvenöse Phase
  • T1 mit chemical Shift Imaging (in-opp-Phase /Dixon) axial
  • T1 GRE fettsupprimiert nativ axial
  • T1 GRE fettsupprimiert spätarteriell axial
  • T1 GRE fettsupprimiert venös axial
  • T1 GRE fettsupprimiert spätvenös axial
  • T1 GRE fettsupprimiert hepatobiliär axial
  • T2 axial
  • T2 koronar
  • Diffusionswichtung b=0-100 s/mm2
  • Diffusionswichtung b=500-1000 s/mm2
, extendedValues=null]], templateType=normal]