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=Radiologischer Befund - Hepatozelluläres Karzinom, 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=Name der Untersuchung, 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=Modalität, 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=Zeitpunkt der Bildgebung, 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=Behandlungssituation, 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=- Initialbefund
- Nach Neoadjuvanz
- Nach lokaler Therapie
- Unter systemischer Therapie
- Verlaufskontrolle ohne Therapie
, 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=Befundtext, 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=Bildgebende Untersuchung Target-Läsionen, 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=Anzahl Target-Läsionen, 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=Zu Target-Läsion, 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=Befund, 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= Terminology: local_terms Default value: Target-Läsion, 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-Läsion Lokalisation, 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=- Lebersegment 1
- Lebersegment 2
- Lebersegment 3
- Lebersegment 4
- Lebersegment 4a
- Lebersegment 4b
- Lebersegment 5
- Lebersegment 6
- Lebersegment 7
- Lebersegment 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=Beschreibung der Läsion, 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=*New element(en), description=**(en), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- *CT/MRT Diagnostisches LI-RADS®(en)
, 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=Befundungsalgorithmus LI-RADS, description=**(en), 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(en)
- *LR-TIV(en)
- *LR-1(en)
- *LR-2(en)
- *LR-3(en)
- *LR-4(en)
- *LR-5(en)
- *LR-M(en)
, 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=*New element(en), description=**(en), 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 Nicht beurteilbar(en)
- *LR-TR Avital(en)
- *LR-TR nicht eindeutig(en)
- *LR-TR vital(en)
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- Restvitalität der Läsion
Default value: Restvitalität der Läsion, 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=Restvitalität, 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=Kommentar zur Restvitalität der Läsion, 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=Größe des vitalen Anteils des HCCs, 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-Läsion Kommentar, 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=Größe der Läsion, 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-Läsionen Kommentar, 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='Pfortaderthrombose'], code=at0000, itemType=CLUSTER, level=5, text=Pfortaderthrombose, 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='Pfortaderthrombose']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Befund, 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=Default value: Pfortaderthrombose, 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='Pfortaderthrombose']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Vorhanden?, 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='Pfortaderthrombose']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Pfortaderthrombose Kommentar, 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='Regionäre Lymphknotenmetastasen'], code=at0000, itemType=CLUSTER, level=5, text=Regionäre Lymphknotenmetastasen, 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='Regionäre Lymphknotenmetastasen']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Befund, 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=- Regionäre Lymphknotenmetastasen
Default value: Regionäre Lymphknotenmetastasen, 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='Regionäre Lymphknotenmetastasen']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Vorhanden?, 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='Regionäre Lymphknotenmetastasen']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Regionäre Lymphknotenmetastasen Kommentar, 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='Fernmetastasen'], code=at0000, itemType=CLUSTER, level=5, text=Fernmetastasen, 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='Fernmetastasen']/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Befund, 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=Default value: Fernmetastasen, 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='Fernmetastasen']/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=6, text=Metastasierungsort, 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='Fernmetastasen']/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Metastasierungsort, 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- Lunge (PUL)
- Knochen (OSS)
- Leber (HEP)
- Hirn (BRA)
- Lymphknoten (LYM)
- Knochenmark (MAR)
- Pleura (PLE)
- Peritoneum (PER)
- Nebenniere (ADR)
- Nieren (KID)
- Haut (SKI)
- Andere Organe (OTH)
- Generalisierte Metastasierung (GEN)
, 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='Fernmetastasen']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Fernmetastasen vorhanden?, 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='Fernmetastasen']/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Fernmetastasen Kommentar, 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=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-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=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_TEXT, bindings=null, values=- PR (partial response)
- SD (stable disease)
- PD (progressive disease)
- CR (complete response)
- U (Beurteilung unmöglich)
- X (Fehlende Angabe)
, 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=Verlaufsbeurteilung Gesamtbefund, 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=- Befundkonstanz
- Befundverbesserung
- Befundverschlechterung
- Divergentes Verhalten
- Beurteilung ist nicht möglich
- Nicht zutreffend (Initialbefund)
, 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=Diagnostische Qualität, 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=- Qualität ausreichend
- Qualität eingeschränkt
- Nicht diagnostisch
, 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 (Studienkennzeichen), 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=Maßnahme-ID, 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 Bildgebendes Verfahren'], code=at0000, itemType=CLUSTER, level=3, text=CT Bildgebendes Verfahren, description=Zur Darstellung der technischen Spezifikationen einer durchgeführten bildgebenden Untersuchung., 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 Bildgebendes Verfahren']/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Bezeichnung des technischen Verfahrens, description=Zur Dokumentation des Typs des durchgeführten bildgebenden Verfahrens., comment=z. B. Diffusionswichtung bei MRT, die Art oder Weg der Verabreichung von Kontrastmittel, Radiopharmazeutika und / oder angewendete Behandlung., 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 Bildgebendes Verfahren']/items[at0014 and name/value='Native Phase'], code=at0014, itemType=ELEMENT, level=4, text=Native Phase, description=Zur Dokumentation des Subtyps des durchgeführten bildgebenden Verfahrens., comment=z. B. Native Phase, Spätarterielle Phase für CT, oder T1 GRE fettsupprimiert spätvenös axial, T2 koronar für MRT, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Native Phase - Ja
- Native Phase - Nein
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- Spätarterielle Phase - Nein
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- Portalvenöse Phase - Nein
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- Spätvenöse Phase - Nein
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- T1 GRE fettsupprimiert nativ axial - Nein
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- T1 GRE fettsupprimiert spätarteriell axial - Nein
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- T1 GRE fettsupprimiert venös axial - Nein
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- T1 GRE fettsupprimiert spätvenös axial - Nein
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- T1 GRE fettsupprimiert hepatobiliär axial - Nein
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- T2 axial - Nein
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- T2 koronar - Nein
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- Diffusionswichtung b=0-100 s/mm2 - Nein
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- Diffusionswichtung b=500-1000 s/mm2 - Nein
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- Extrazelluläres KM
- Leberspezifisches KM
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