Elston-Ellis-Score-Entry (Template)
(Teildokument von Arztbrief 2.x)
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Version vom 10. Oktober 2013, 13:19 Uhr
Dieses Material ist Teil des Leitfadens Arztbrief 2.x.
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Inhaltsverzeichnis
Elston-Ellis-Score Entry (Template) (Nottingham-Grading)
| Template-Metadaten | |
| Template-Typ | Entry |
| Template ID | <OID für das Template> |
| generischeres Template | Assessment Scales |
| genutzte Templates | |
| nutzende Templates | Grading |
| abgeleitete Templates | |
| Generelle Beschreibung | Diese Seite beschreibt die Darstellung des Elston-Ellis-Scores |
| allg. Erläuterung | Scores_und_Assessments |
| Verhältnis zu IHE | neu |
| Ballotierungsstatus | in Arbeit |
| Erweiterbarkeit | geschlossen |
Übersicht
Die Elemente werden, sofern spezialisiert/abweichend vom übergeordneten Template, hier als Walk Through beschrieben:
| Lvl | RIM | Name | DT | Kard | Conf | Beschreibung |
|---|---|---|---|---|---|---|
| 1 | act | observation | 1..1 | M | Elston-Ellis-Score (Nottingham) | |
| 2 | act | code | CD CWE | 1..1 | F | @code: "396293007", @codeSystem: 2.16.840.1.113883.6.96 |
| 2 | act | value | CD CWE | 1..1 | M | Wert aus dem Scoresystem. Value Set: todo.valueset.xxy004 |
| 2 | rel | entryRelationship | 0..1 | O | 1. Komponente | |
| 3 | act | observation | 1..1 | O | Tubulusbildung (Tubule formation score) | |
| 4 | act | code | CD CWE | 1..1 | F | @code: "371470008", @codeSystem: 2.16.840.1.113883.6.96 |
| 4 | act | value | CD CWE | 1..1 | M | Value Set: todo.valueset.xxy005 |
| 2 | rel | entryRelationship | 0..1 | O | 2. Komponente | |
| 3 | act | observation | 1..1 | O | Kernpolymorphie (Nuclear pleomorphism score) | |
| 4 | act | code | CD CWE | 1..1 | F | @code: "371471007", @codeSystem: 2.16.840.1.113883.6.96 |
| 4 | act | value | CD CWE | 1..1 | M | Value Set: todo.valueset.xxy006 |
| 2 | rel | entryRelationship | 0..1 | O | 3. Komponente | |
| 3 | act | observation | 1..1 | O | Mitoserate (Number of mitoses per 10 high power fields) | |
| 4 | act | code | CD CWE | 1..1 | F | @code: "406094009", @codeSystem: 2.16.840.1.113883.6.96 |
| 4 | act | value | CD CWE | 1..1 | M | Value Set: todo.valueset.xxy007 |
Value Sets
Elston-Ellis-Score
Value Set OID: todo.valueset.xxy004
Code System OID: todo.codesystem.xxy004
| Code | Bedeutung (Kurztext) | Bemerkung |
|---|---|---|
| 3 | Elston-Ellis-Score 3 | |
| 4 | Elston-Ellis-Score 4 | |
| 5 | Elston-Ellis-Score 5 | |
| 6 | Elston-Ellis-Score 6 | |
| 7 | Elston-Ellis-Score 7 | |
| 8 | Elston-Ellis-Score 8 | |
| 9 | Elston-Ellis-Score 9 |
Tubulusbildung
Value Set OID: todo.valueset.xxy005
Code System OID: 2.16.840.1.113883.6.96
| Code | Bedeutung (Kurztext) | Bemerkung |
|---|---|---|
| 369778004 | > 75% | Breast tubule formation: Majority of tumor >75% (score = 1) |
| 369779007 | 10-75% | Breast tubule formation: Moderate 10% to 75% (score = 2) |
| 369780005 | < 10% | Breast tubule formation: Minimal <10% (score = 3) |
Kernpolymorphie
Value Set OID: todo.valueset.xxy006
Code System OID: 2.16.840.1.113883.6.96
| Code | Bedeutung (Kurztext) | Bemerkung |
|---|---|---|
| 384735004 | gering | Nuclear pleomorphism: small regular nuclei (score=1) |
| 384737007 | mäßig | Nuclear pleomorphism: moderate increase in size, etc (score = 2) |
| 384738002 | stark | Nuclear pleomorphism: marked variation in size, nucleoli, chromatin clumping, etc (score = 3) |
Mitoserate
Die Grundlage dieses Scores (Anzahl Mitosen/10 HPF) ist von der Beobachtungssituation des Pathologen abhängig (Größe des Gesichtsfeldes). Daher wird hier nicht die hierauf fixierte Codierung aus SNOMED-CT verwendet.
Value Set OID: todo.valueset.xxy007
Code System OID: todo.codesystem.xxy007
| Code | Bedeutung (Kurztext) | Bemerkung |
|---|---|---|
| 1 | Score = 1, z.B. SFZ 25: 0-10 / SFZ 20: 0-8 | |
| 2 | Score = 2, z.B. SFZ 25: 11-20 / SFZ 20: 9-16 | |
| 3 | Score = 3, z.B. SFZ 25: > 20 / SFZ 20: > 16 |
Beispiel
<observation moodCode='EVN' classCode='OBS'>
<templateID root='' />
<id root='' extension='' />
<code code='396293007' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='7' codeSystem='todo.codesystem.xxy004'/>
<entryRelationship typeCode='COMP'>
<observation moodCode='EVN' classCode='OBS'>
<code code='371470008' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='369780005' codeSystem='2.16.840.1.113883.6.96'/>
</observation>
</entryRelationship>
<entryRelationship typeCode='COMP'>
<observation moodCode='EVN' classCode='OBS'>
<code code='371471007' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='384737007' codeSystem='2.16.840.1.113883.6.96'/>
</observation>
</entryRelationship>
<entryRelationship typeCode='COMP'>
<observation moodCode='EVN' classCode='OBS'>
<code code='406094009' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='2' codeSystem='todo.codesystem.xxy007'/>
</observation>
</entryRelationship>
</observation>
