| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-SECTION.problem_list.v0, otherContributors=Katrin Tröltzsch, Heidelberg University Hospital, Germany, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0], code=at0000, itemType=SECTION, level=0, text=Tumordiagnose_section, description=Framework for consistent modelling of content within a template for a Problem list., comment=Intended to be used within the COMPOSITION.problem_list., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose'], code=at0000, itemType=EVALUATION, level=1, text=Tumordiagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Diagnose Name (ICD-10), description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Diagnose Beschreibung, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Seitenlokalisation, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record 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 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Links (L)
- Rechts (R)
- Beidseitig (B)
- Mittellinie/ Mittig (M)
- Unbekannt (U)
- Trifft nicht zu (T; Seitenangabe nicht sinnvoll, einschließlich Systemerkrankungen)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Erstdiagnosedatum, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0], code=at0000, itemType=CLUSTER, level=3, text=Tumor classification ICD-O, description=International Classification of Diseases for Oncology.
ICD-O-3 is a dual classification. It contains both a topographical code and a histological code for each neoplasm.
The topographical describes the site of the neoplasm; in general, it uses the same three- or four-character codes as used in ICD-10 for malignant neoplasms. This results in a greater accuracy in the encoding of the topography of benign tumors than achieved in ICD-10.
The morphological code describes the cell type of the neoplasm and its biological behaviour. It thus characterises the neoplasm itself., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Morphological Code ICD-O, description=To record the type of cell that has become neoplastic and its biologic activity with the morphology code according to the International classification of diseases for oncology (ICD-O)., comment=There are three parts to a complete morphology code:
4 digits – Cell type (histology)
1 digit – Behavior
1 digit – Grade, differentiation or phenotype
In ICD-O morphology codes, a common root codes the cell type of a given tumor, while an additional digit codes the behavior. The grade, differentiation, or phenotype code provides supplementary information about the tumor., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://hl7.org/fhir/sid/icd-o-3
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/morphologie-icdo3- 8822/1 | Abdominale Fibromatose
- 8504/2 | Abgekapseltes papilläres Karzinom
- 8504/3 | Abgekapseltes papilläres Karzinom mit Invasion
- 8343/3 | Abgekapseltes papilläres Karzinom[C73.9]
- 8158/3 | ACTH-produzierender Tumor
- 9261/3 | Adamantinom der langen Röhrenknochen[C40.-]
- 9351/1 | Adamantinöses Kraniopharyngeom[C75.2]
- 8210/2 | Adenocarcinoma in situ in adenomatösem Polypen
- 8263/2 | Adenocarcinoma in situ in tubulovillösem Adenom
- 8261/2 | Adenocarcinoma in situ in villösem Adenom
- 8140/2 | Adenocarcinoma in situ o.n.A.
- 9013/0 | Adenofibrom o.n.A.
- 8200/3 | Adenoid-zystisches Karzinom
- 8098/3 | Adenoides Basalzellkarzinom[C53.-]
- 8075/3 | Adenoides Plattenepithelkarzinom
- 8245/3 | Adenokarzinoidtumor
- 8215/3 | Adenokarzinom der Analdrüsen[C21.1]
- 8390/3 | Adenokarzinom der Hautanhangsgebilde o.n.A.[C44.-]
- 8210/3 | Adenokarzinom in adenomatösem Polypen
- 8220/3 | Adenokarzinom in familiärer adenomatöser Polypose [FAP][C18.-]
- 8221/3 | Adenokarzinom in multiplen adenomatösen Polypen
- 8263/3 | Adenokarzinom in tubulovillösem Adenom
- 8261/3 | Adenokarzinom in villösem Adenom
- 8573/3 | Adenokarzinom mit apokriner Metaplasie
- 8255/3 | Adenokarzinom mit gemischten Subtypen
- ... +1120
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Morphologie Beschreibung, description=To record the term (narrative description/synonyms) of the morphology code according to the International classification of diseases for oncology (ICD-O)., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Topography Code ICD-O, description=The topographical describes the site of the neoplasm., comment=In general, it uses the same three- or four-character codes as used in ICD-10 for malignant neoplasms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://terminology.hl7.org/CodeSystem/icd-o-3
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.medizininformatik-initiative.de/fhir/ext/modul-biobank/ValueSet/icd-o-3-topography- C76.2 | Abdomen o.n.A.
- C24.1 | Ampulla Vateri
- C21.1 | Analkanal
- C21 | Analkanal und Anus
- C76-C80 | Anderer oder mangelhaft bezeichneter Sitz
- C16.3 | Antrum ventriculi
- C21.0 | Anus o.n.A.
- C18.1 | Appendix vermiformis
- C30-C39 | Atemwege [Respirationstrakt] und intrathorakale Organe
- C39.8 | Atemwege [Respirationstrakt] und intrathorakale Organe, mehrere Bereiche überlappend
- C69.9 | Auge o.n.A.
- C69 | Auge und Augenanhangsgebilde
- C69.8 | Auge und Augenanhangsgebilde, mehrere Teilbereiche überlappend
- C69-C72 | Auge, Gehirn und sonstige Teile des Zentralnervensystems
- C44.1 | Augenlid
- C47.9 | Autonomes Nervensystem o.n.A.
- C76.3 | Becken o.n.A.
- C41.4 | Beckenknochen, Kreuzbein, Steißbein und zugehörige Gelenke
- C77.5 | Beckenlymphknoten
- C44.4 | Behaarte Kopfhaut und Haut am Hals
- C49 | Bindegewebe, Subkutangewebe und sonstige Weichteile
- C49-C49 | Bindegewebe, Subkutangewebe und sonstige Weichteile
- C49.1 | Bindegewebe, Subkutangewebe und sonstige Weichteile der oberen Extremität und der Schulter
- C49.2 | Bindegewebe, Subkutangewebe und sonstige Weichteile der unteren Extremität und der Hüfte
- C49.5 | Bindegewebe, Subkutangewebe und sonstige Weichteile des Beckens
- ... +391
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_icdo.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Topographie Beschreibung, description=To record the term (narrative description/synonyms) of the topography code according to the "International classification of diseases for oncology (ICD-O-3)"., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1], code=at0000, itemType=CLUSTER, level=3, text=TNM clinical classification, description=A framework for the clinical classification and stage grouping of malignancies using the TNM system., comment=Designated as TNM or cTNM., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Primary tumour (T), description=Assessment of the the extent of the primary tumour., comment=Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'T1'; or 'cT3'. Represented as 'T' or 'cT' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 1
- 1a
- 1a1
- 1a2
- 1b
- 1b1
- 1b2
- 1c
- 1c1
- 1c2
- 1c3
- 1d
- 1mic
- 2
- 2a
- 2a1
- 2a2
- 2b
- 2c
- 2d
- 3
- 3a
- 3b
- 3c
- 3d
- 3e
- 4
- 4a
- 4b
- 4c
- 4d
- 4e
- a
- is
- is(DCIS)
- is(LAMN)
- is(LCIS)
- is(Paget)
- is(pd)
- is(pu)
- X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Regional lymph nodes (N), description=Assessment of the the absence or presence and extent of regional lymph node metastasis., comment=Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'NX'; or 'cN2'. Represented as 'N' or 'cN' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 0(i+)
- 0(i-)
- 0(i-)(sn)
- 0(mol+)
- 0(mol-)
- 1
- 1a
- 1a(sn)
- 1b
- 1b a)
- 1b b)
- 1b c)
- 1b d)
- 1c
- 1mi
- 2
- 2a
- 2b
- 2c
- 3
- 3a
- 3b
- 3c
- 4
- X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Distant metastasis (M), description=Assessment of the absence or presence of distant metastasis., comment=Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'M1'; 'cM1a'; 'M1 PUL'; or 'cM0'. Represented as 'M' or 'cM' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- X
- 0
- 1
- 1a
- 1b
- 1bi
- 1bii
- 1biii
- 1biv
- 1c
- 1d
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R2 (Macroscopic residual tumour)'. Represented as 'R' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'. Represented as 'L' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'. Represented as 'V' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'. Represented as 'Pn' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Represented by the suffix, either as '(m)' or the number of primary tumours added to the T code in brackets . For example: 'T2(m)' or 'cT2(4)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Count Boolean
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Multimodality therapy (y), description=Record as True if assessment is performed during or following initial multimodal therapy., comment=Represented by the prefix 'y' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Recurrent (r), description=Record as True if assessment is performed for a recurring cancer after a disease-free interval., comment=Represented by the prefix 'r' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Carcinoma in situ (is), description=Record as True if presence of carcinoma in situ associated with the primary tumour., comment=Represented by the prefix 'is' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=TNM assessment, description=Concatenation of 'T', 'N' and 'M' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0031], code=at0031, itemType=ELEMENT, level=4, text=Stage grouping, description=The categorisation of the anatomical stage of the tumour, usually based on TNM assessment., comment=For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 0a
- 0is
- I
- IA
- IA1
- IA2
- IA3
- IB
- IS
- II
- IIA
- IIB
- IIC
- III
- IIIA
- IIIB
- IIIC
- IIID
- IV
- IVA
- IVB
- IVC
- kein Stadtium ermittelbar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=TNM Edition, description=The edition of the TNM classification system used for the assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Auflage 8
- Auflage 7
- Auflage 6
- Auflage 5
- Auflage 4
- Auflage 3
- Auflage 2
- Auflage 1
Default value: Auflage 8, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1], code=at0000.1, itemType=CLUSTER, level=3, text=TNM pathological classification, description=A framework for the pathological classification and stage grouping of malignancies using the TNM system., comment=Designated as pTNM., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0003.1], code=at0003.1, itemType=ELEMENT, level=4, text=Primary tumour (pT), description=Assessment of the extent of the primary tumour., comment=Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'pT1'; or 'pT3'. Represented as 'pT' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 1
- 1a
- 1a1
- 1a2
- 1b
- 1b1
- 1b2
- 1c
- 1c1
- 1c2
- 1c3
- 1d
- 1mic
- 2
- 2a
- 2a1
- 2a2
- 2b
- 2c
- 2d
- 3
- 3a
- 3b
- 3c
- 3d
- 3e
- 4
- 4a
- 4b
- 4c
- 4d
- 4e
- a
- is
- is(DCIS)
- is(LAMN)
- is(LCIS)
- is(Paget)
- is(pd)
- is(pu)
- X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0004.1], code=at0004.1, itemType=ELEMENT, level=4, text=Regional lymph nodes (pN), description=Assessment of the absence or presence and extent of regional lymph node metastasis., comment=Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'pNX'; or 'pN2'. Represented as 'pN' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 0(i+)
- 0(i-)
- 0(i-)(sn)
- 0(mol+)
- 0(mol-)
- 1
- 1a
- 1a(sn)
- 1b
- 1b a)
- 1b b)
- 1b c)
- 1b d)
- 1c
- 1mi
- 2
- 2a
- 2b
- 2c
- 3
- 3a
- 3b
- 3c
- 4
- X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0005.1], code=at0005.1, itemType=ELEMENT, level=4, text=Distant metastasis (pM), description=Assessment of the absence or presence of distant metastasis., comment=Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'pM1'. Represented as 'pM' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- X
- 0
- 1
- 1a
- 1b
- 1bi
- 1bii
- 1biii
- 1biv
- 1c
- 1d
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Histopathological grade (G), description=Histopathological grading of the tumour., comment=Pretreatment histopathological assessment may be determined from a limited biopsy prior to formal resection. Coding with a G code appropriate for the identified tumour type and anatomical site is expected. For example: 'G2'; 'GX'; or 'low grade' for bone and soft tissue sarcoma classification. Represented as 'G' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 1
- 2
- 3
- 4
- Differenzierungsgrad nicht bestimmbar
- Niedriggradig maligne
- Mittelgradig maligne
- Hochgradig maligne
- Trifft nicht zu
- Borderline
- Unbekannt
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R2 (Macroscopic residual tumour)'. Represented as 'R' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'. Represented as 'L' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'. Represented as 'V' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'. Represented as 'Pn' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0025.1], code=at0025.1, itemType=ELEMENT, level=4, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Represented by the suffix, either as '(m)' or the number of primary tumours added to the T code. For example: 'pT2(m)' or 'pT2(4)'. Represented as 'pm' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Count
- Boolean
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Multimodality therapy (y), description=Record as True if assessment is performed during or following initial multimodal therapy., comment=Represented by the prefix 'y' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Recurrent (r), description=Record as True if assessment is performed for a recurring cancer after a disease-free interval., comment=Represented by the prefix 'r' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=4, text=Autopsy (a), description=Record as True if assessment is performed at postmortem examination., comment=Represented by the prefix 'a' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Carcinoma in situ (is), description=Record as True if presence of carcinoma in situ associated with the primary tumour., comment=Represented by the prefix 'is' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0030.1], code=at0030.1, itemType=ELEMENT, level=4, text=pTNM assessment, description=Concatenation of 'pT', 'pN' and 'pM' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0031.1], code=at0031.1, itemType=ELEMENT, level=4, text=Stage grouping, description=The categorisation of the anatomical stage of the tumour, usually based on pTNM assessment., comment=For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 0
- 0a
- 0is
- I
- IA
- IA1
- IA2
- IA3
- IB
- IS
- II
- IIA
- IIB
- IIC
- III
- IIIA
- IIIB
- IIIC
- IIID
- IV
- IVA
- IVB
- IVC
- kein Stadium ermittelbar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=TNM Edition, description=The edition of the TNM classification system used for the assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Auflage 8
- Auflage 7
- Auflage 6
- Auflage 5
- Auflage 4
- Auflage 3
- Auflage 2
- Auflage 1
Default value: Auflage 8, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.1], code=at0.1, itemType=ELEMENT, level=4, text=Sentinel node (sn), description=Record as True if presence of metastasis within one or more sentinel node(s)., comment=Represented by the suffix 'sn' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.2], code=at0.2, itemType=ELEMENT, level=4, text=Micrometastases (mi), description=Record as True if presence of micrometastases in the regional lymph drainage area of the primary tumour., comment=Represented by the suffix 'mi' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.3], code=at0.3, itemType=ELEMENT, level=4, text=Regional lymph node ITC, description=Presence of isolated tumour cells (ITC) detected by H&E stains or immunohistochemistry in regional lymph nodes., comment=For example 'pN0(i-) No regional lymph node metastasis histologically, negative morphological findings for ITC'; 'pN0(mol+) No regional lymph node metastasis histologically, positive non morphological findings for ITC'; or 'pN0(i+)(sn) No sentinel lymph node metastasis histologically, positive morphological findings for ITC'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.8], code=at0.8, itemType=ELEMENT, level=4, text=Distant metastasis ITC, description=Presence of isolated tumour cells (ITC) detected by H&E stains or immunohistochemistry as distant metastases, such as bone marrow., comment=For example: 'pM0(i+)' or 'pM0(mol+)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2], code=at0000, itemType=CLUSTER, level=3, text=Tumor_Diagnosesicherung, description=Beschreibt die höchste erreichte Diagnosesicherheit, die in der Krankenakte des Patienten vermerkt ist. Außerdem kann dargestellt werden, welche Verfahren zur Krebsdiagnose verwendet wurden., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0094], code=at0094, itemType=ELEMENT, level=4, text=Höchste Diagnosesicherheit, description=Die höchste erreichte Diagnosesicherheit zum Diagnosedatum., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Klinisch ohne tumorspezifische Diagnostik
- Klinisch
- Spezifische Tumormarker
- Zytologisch
- Histologie einer Metastase
- Histologisch
- Unbekannt
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017], code=at0017, itemType=CLUSTER, level=4, text=Diagnosesicherung, description=Zur Dokumentation der Methode, des Verfahrens oder der Information, auf welcher die Diagnosesicherheit beruht., comment=Zum Beispiel: klinisches- oder bildgebendes Verfahren, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0102], code=at0102, itemType=CLUSTER, level=5, text=Klinisch, description=Die Diagnosesicherheit beruht auf einer klinischen Identifikation des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0102]/items[at0103], code=at0103, itemType=ELEMENT, level=6, text=Klinisches Verfahren, description=Es wurde weder ein mikroskopisches, noch ein bildgebendes Verfahren für die Diagnose genutzt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Direkte Visualisierung
- Ausschließlich klinische Diagnostik
- Palpation
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0102]/items[at0107], code=at0107, itemType=ELEMENT, level=6, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0108], code=at0108, itemType=CLUSTER, level=5, text=Bildgebung, description=Die Malignität wurde mit Hilfe eines bildgebenden Verfahrens durch den Kliniker berichtet., comment=null, uncommonOntologyItems=null, occurencesFormal=0..7, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0108]/items[at0109], code=at0109, itemType=ELEMENT, level=6, text=Bildgebende Verfahren, description=Die Malignität wurde mit Hilfe eines bildgebenden Verfahrens durch den Kliniker berichtet., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- MRT
- CT
- PET
- PET-CT
- PET-MRT
- SPECT
- Sonstige Nuklearmedizinische Bildgebung
- Sonografie
- Röntgendiagnostik
- Anderes bildgebendes Verfahren
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0108]/items[at0116], code=at0116, itemType=ELEMENT, level=6, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0117], code=at0117, itemType=CLUSTER, level=5, text=Mikroskopisch, description=Die Diagnosesicherheit beruht auf einer mikroskopischen Identifikation des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=0..6, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0117]/items[at0118], code=at0118, itemType=ELEMENT, level=6, text=Mikroskopisches Verfahren, description=Die Diagnosesicherheit beruht auf einer mikroskopischen Identifikation des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Histologisch
- Immunophänotypisierung
- Mikroskopische Bestätigung mit unbekannter Methode
- Labortest oder Labormarker
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0117]/items[at0127], code=at0127, itemType=ELEMENT, level=6, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0125], code=at0125, itemType=CLUSTER, level=5, text=Sonstige Verfahren, description=Die Diagnosesicherheit beruht auf einem alternativen Verfahren, welches in den vorherigen Elementen nicht dargestellt wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0125]/items[at0126], code=at0126, itemType=ELEMENT, level=6, text=Sonstiges Verfahren, description=Die Diagnosesicherheit beruht auf einem alternativen Verfahren, welches in den vorherigen Elementen nicht dargestellt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text Coded Text- Genetischer Test
- Zytologisch
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0125]/items[at0128], code=at0128, itemType=ELEMENT, level=6, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v2]/items[at0017]/items[at0129], code=at0129, itemType=ELEMENT, level=5, text=Kommentar, description=Weitere Informationen über die Erhebung der Diagnosesicherheit., comment=Zum Beispiel können Anmerkungen über Qualität der Diagnosesicherheit in diesem Datenelement festgehalten werden., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1], code=at0000, itemType=CLUSTER, level=3, text=Weitere Tumorklassifikation, description=Der Archetyp "Weitere Tumorklassifikation" dient zur Stadieneinteilung maligner Neoplasien nach sonstigen, weiteren Tumorklassifikationen, außer der TNM-Klassifikation., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Name der Klassifikation, description=Angabe der Bezeichnung der Klassifikation. Wenn möglich wird die Kodierung der spezifischen Klassifikation mit einer Terminologie bevorzugt., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Beschreibung des Stadium/Gruppe/Grades, description=Jede zusätzliche Beschreibung für die entsprechende Klassifikation., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Stadium/Gruppe/Grad, description=Das Stadium/die Gruppe/der Grad der Einstufung der Malignität anhand der Klassifikation., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Datum der Klassifizierungseinteilung, description=Das Datum, an dem die Klassifikation festgestellt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Auflage der Klassifikation, description=Die Auflage, auf der die Klassifikation basiert, die für die Beurteilung verwendet wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Kommentar, description=Ergänzende Beschreibung der weiteren Tumorklassifikation, die nicht in anderen Bereichen erfasst wurde., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumour_focality.v0], code=at0000, itemType=CLUSTER, level=3, text=Tumorfokalität, description=Beschreibt die Fokalität bzw. das Herdgeschehen des Tumors bei einem Krebspatienten., comment=Der Fokus bezeichnet den Herd bzw. Streuherd im Sinne eines lokalen Krankheitsprozesses, der über die direkte Umgebung hinaus pathologische Fernwirkungen auslösen kann., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumour_focality.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Fokalität, description=Fokalität bzw. das Herdgeschehen des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Unifokal
- Bifokal
- Multifokal
- Unbekannt/unzureichend beschrieben
- Systemisch
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumour_focality.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Beschreibung der Fokalität, description=Beschreibung des Herdgeschehens des Tumors., comment=Zum Beispiel "Diffus wachsend", "Multizentrisches Mammakarzinom mit 3 Herden" oder "Nachweis von Tumorzellen im Liquorsediment"., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Kommentar Tumordiagnose, description=Additional narrative about the problem or diagnosis 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/protocol[at0032], code=at0032, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Last updated, description=The date this problem or diagnosis was last updated., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0], code=at0000, itemType=CLUSTER, level=3, text=Tumor ID, description=Zur Darstellung der ID des Tumors., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Tumor ID, description=Die ID/Kennung des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase'], code=at0000, itemType=EVALUATION, level=1, text=Fernmetastase, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Fernmetastase, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms- Keine Fernmetastasen
- Fernmetastase
Default value: Keine Fernmetastasen, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Fernmetastase Lokalisation, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record 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 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Fernmetastase Diagnosedatum, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the problem or diagnosis 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/protocol[at0032], code=at0032, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Last updated, description=The date this problem or diagnosis was last updated., 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=1, text=Absence of information, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.absence.v2]/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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Absence statement, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal] |