TEMPLATE Nuklearmedizinische onkologische Therapie (Nuklearmedizinische onkologische Therapie)

TEMPLATE IDNuklearmedizinische onkologische Therapie
ConceptNuklearmedizinische onkologische Therapie
DescriptionZur Repräsentation von Daten zu einer Nuklearmedizinischen Therapie eines Patienten mit einer hepatobiliären, onkologischen Diagnose im HiGHmed Projekt.
UseDieses Template wird verwendet, um Daten zu einer Nuklearmedizinischen Therapie von Patienten mit einer hepatobiliären, onkologischen Diagnose zu verzeichnen. Es sollen folgende Daten zu der Nuklearmedizinischen Therapie wie Zielgebiet der Bestrahlung, Beginn und Ende, Applikationsart, Strahlenart, Dosis, Relation zur OP, Grund für das Ende der Therapie, Gesamtansprechen, Anmerkungen und Intention erfasst werden.
MisuseDieses Template soll nicht verwendet werden, um andere Therapien oder Prozeduren des Patienten zu verzeichnen. Für diese Daten sind jeweils andere Templates zu benutzen.
PurposeZur Repräsentation von Daten zu einer Nuklearmedizinischen Therapie eines Patienten mit einer hepatobiliären, onkologischen Diagnose im HiGHmed Projekt.
References
Authorsdate: 2019-12-03; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Alina Rehberg
Other Details Languagedate: 2019-12-03; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Alina Rehberg
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=544eba2f9be1b5430b94531379ffd07d, sem_ver=4.0.0}
KeywordsNuklearmedizinische Therapie; Nuklearmedizinisch; Nuklearmedizinische Behandlung; Nuklearmedizin
Language useden
Citeable Identifier1246.169.882
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  • Zwischenbericht
  • Endbericht
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapiemethode
  • 03 | Brachytherpie 
  • 01 | Metabolische Therapie 
  • 99 | Sonstige Therapie 
  • 02 | Teletherapie 
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  • Neoadjuvant 
  • Adjuvant 
  • Ohne Bezug zur OP 
  • Intraoperativ 
  • Alleinige Therapie 
  • Sonstiges 
  • Unbekannt 
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapieansprechen
  • U | Beurteilung unmoeglich 
  • CR | complete respone 
  • X | Fehlende Angaben 
  • MR | mixed response 
  • PR | partial response 
  • PD | progressive disease 
  • SD | stable disease 
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  • Leber 
  • Ganzkörperbestrahlung 
  • Unbekannt 
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  • nicht zutreffend
  • rechter Leberlappen
  • linker Leberlappen
  • Lebersegment 1
  • Lebersegment 2
  • Lebersegment 3
  • Lebersegment 4
  • Lebersegment 4a
  • Lebersegment 4b
  • Lebersegment 5
  • Lebersegment 6
  • Lebersegment 7
  • Lebersegment 8
  • rechter Leberlappen (caudal)
  • rechter Leberlappen (cranial)
  • linker Leberlappen (caudal)
  • linker Leberlappen (cranial)
  • [...]
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  • Metabolic therapy 
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/applikationsart-nuklearmedizinische-therapie
  • 02 | Metabolische Therapie: Peptid-Radio-Rezeptor-Therapie(PRRT) 
  • 01 | Metabolische Therapie: Selektive interne Radio-Therapie (SIRT) 
  • 03 | Radio-Immuntherapie 
  • 00 | Unbekannt 
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  • Gy 
  • GyE 
  • GBq 
  • MBq 
  • kBq 
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  • Gy 
  • GyE 
  • GBq 
  • MBq 
  • kBq 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1], code=at0000, itemType=CLUSTER, level=3, text=Nebenwirkungen, description=Reported observation of a physical or mental disturbance in an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0], code=at0000, itemType=CLUSTER, level=4, text=Common Terminology Criteria for Adverse Events (CTCAE), description=A framework for recording any unfavourable and unintended sign, symptom or disease temporally using the CTCAE terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=System Organ Class (SOC), description=The category of the 'Term' in the MedDRA hierarchy., comment=Identified as a MedDRA primary class - representing an anatomical or physiological system, aetiology or purpose., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Term, description=The name of the sign, symptom or disease observed., comment=Identified as a MEDRAterm and corresponding code., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Grade, description=The severity of the Adverse event., comment=For each Grade, non-specific comments provide some general guidance about the severity for each grade and are represented within square brackets []. In practice, each grade will be represented by a specific clinical description, appropriate for the selected term and will likely be sourced from an external knowledgebase or resource., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: Grade 1 
  • 2: Grade 2 
  • 3: Grade 3 
  • 4: Grade 4 
  • 5: Grade 5 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.ctcae.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=CTCAE version, description=The version of the CTCAE terminology used., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0048], code=at0048, itemType=ELEMENT, level=3, text=Ende Grund, description=Outcome of procedure performed., comment=Coding with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://highmed.org/fhir/CodeSystem/onko/therapieende-grund
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/therapieende-grund
  • AG | Abbruch aus sonstigen Gruenden 
  • AA | Abbruch wegen Nebenwirkung/Toxizitaet 
  • AP | Abbruch wegen Progress 
  • AV | Patient verweigert weitere Therapie 
  • AE | Regulaeres Ende 
  • AR | Regulaeres Ende mit Dosisreduktion 
  • AX | Unbekannt 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Intention, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://highmed.org/fhir/CodeSystem/onko/intention-der-therapie
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/intention-der-therapie
  • D | Diagnostisch 
  • X | Fehlende Angaben/ Keine Angaben 
  • K | Kurativ 
  • O | Lokal kurativ bei Oligometastasierung 
  • P | Palliativ 
  • R | Revision/ Komplikation 
  • S | Sonstiges 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Anmerkungen, description=Additional narrative about the activity or care pathway step not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053], code=at0053, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053]/items[at0054], code=at0054, itemType=ELEMENT, level=3, text=Nuklearmedizische Therapie ID, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service., comment=This is equivalent to Placer Order Number in HL7 v2 specifications., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Identifier
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0], code=at0000, itemType=SECTION, level=1, 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-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, 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-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, 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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, 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-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, 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-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0], code=at0000, itemType=CLUSTER, level=4, 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-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.tumor_id.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, 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]], templateType=normal]