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 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0049], code=at0049, itemType=ELEMENT, level=3, text=Beschreibung (optional), description=Narrative description about the procedure, as appropriate for the pathway step., comment=For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.relation_to_operation.v1], code=at0000, itemType=CLUSTER, level=3, text=Relation zur OP, description=Zur Darstellung des Bezugs einer Strahlentherapie, systemischen Therapie und/oder sonstigen Therapie zu einer operativen Therapie (OP)., 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.relation_to_operation.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Stellung zur OP, description=Der Bezug einer Strahlentherapie, einer systemischen Therapie oder einer sonstigen Therapie zu einer operativen Therapie (OP)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Neoadjuvant 
  • Adjuvant 
  • Ohne Bezug zur OP 
  • Intraoperativ 
  • Alleinige Therapie 
  • Sonstiges 
  • Unbekannt 
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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-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.response_to_treatment.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, 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. 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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: Zielgebiet
  • Leber 
  • Ganzkörperbestrahlung 
  • Unbekannt 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.radiotherapy.v1]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Spezifische Körperstelle / Zielvolumen, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 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=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Intention, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Anmerkungen, 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
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