TNM-Klassifikation-Entry (Template)

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{| class="hl7table"
 
{| class="hl7table"
Zeile 147: Zeile 142:
 
| 1..1
 
| 1..1
 
| required
 
| required
|  
+
| fix: @classCode="OBS", @moodCode="EVN"
 
 
|-
 
| 4
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 4
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
  
 
|-
 
|-
Zeile 174: Zeile 151:
 
| 1..1
 
| 1..1
 
| required
 
| required
| TNM-Klassifikation
+
|fix: @root="1.2.276.0.76.3.1.131.1.10.3.5"
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| @root
 
|
 
| 1..1
 
| required
 
| fix: "1.2.276.0.76.3.1.131.1.10.3.5"
 
 
 
 
|-
 
|-
 
| 4
 
| 4
Zeile 219: Zeile 186:
 
| 1..1
 
| 1..1
 
| required
 
| required
|  
+
| fix: @code="tnmStage", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmStage"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
Zeile 246: Zeile 195:
 
|1..1
 
|1..1
 
|required
 
|required
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
+
|textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
  
 
|-
 
|-
Zeile 264: Zeile 213:
 
|1..1
 
|1..1
 
|required
 
|required
|Code für das UICC-Stadium
+
|Code für das UICC-Stadium<br>
 +
fix: @codeSystem="2.16.840.1.113883.15.6"
  
 
|-
 
|-
Zeile 276: Zeile 226:
  
 
|-
 
|-
|5
+
| 4
|bgcolor="ff8888"|act
+
|bgcolor="ffaaaa"| rel
|@codeSystem
+
| entryRelationship
|
+
|  
|1..1
+
| 0..1
|required
+
| optional
|fix: "2.16.840.1.113883.15.6"
+
| fix: @typeCode="SPRT"
  
 
|-
 
|-
|5
+
| 5
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
 
|bgcolor="ff8888"| act
 
|bgcolor="ff8888"| act
| name
+
| observation
| CV
+
|  
 
| 1..1
 
| 1..1
 
| required
 
| required
| TNM a-Symbol (Präfix): Stadium bei Autopsie festgestellt
+
| TNM a-Symbol (Präfix): Stadium bei Autopsie festgestellt<br>
 
+
fix: @classCode="OBS", @moodCode="EVN"
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmASymbol"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|Code für das a-Symbol
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "a"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
  
 
|-
 
|-
 
| 6
 
| 6
 
|bgcolor="ff8888"| act
 
|bgcolor="ff8888"| act
| name
+
| code
| CV
+
| CD CWE
 
| 1..1
 
| 1..1
 
| required
 
| required
| TNM y-Symbol (Präfix): Stadium nach neoadjuvanter Therapie
+
| fix: @code="tnmASymbol", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmYSymbol"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
 
|6
 
|6
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
|value
+
|text
|CV
+
|ED
|1..1
 
|required
 
|Code für das y-Symbol
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "y"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| TNM r-Symbol (Präfix): Stadium eines Rezidivs
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmRSymbol"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
 
|1..1
 
|1..1
 
|required
 
|required
|fix: "1.2.276.0.76.3.1.131.1.5.1"
+
|textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
  
 
|-
 
|-
Zeile 450: Zeile 266:
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|value
 
|value
|CV
+
|BL
|1..1
 
|required
 
|Code für das r-Symbol
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
 
|1..1
 
|1..1
 
|required
 
|required
|fix: "r"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
 
|
 
|
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
  
 
|-
 
|-
Zeile 480: Zeile 278:
 
| 0..1
 
| 0..1
 
| optional
 
| optional
|  
+
| fix: @typeCode="SPRT"
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
  
 
|-
 
|-
Zeile 495: Zeile 284:
 
|bgcolor="ff8888"| act
 
|bgcolor="ff8888"| act
 
| observation
 
| observation
|
 
| 1..1
 
| required
 
 
|  
 
|  
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
 
| 1..1
 
| 1..1
 
| required
 
| required
| fix: "OBS"
+
| TNM y-Symbol (Präfix): Stadium nach neoadjuvanter Therapie
 
+
fix: @classCode="OBS", @moodCode="EVN"
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
  
 
|-
 
|-
Zeile 525: Zeile 297:
 
| 1..1
 
| 1..1
 
| required
 
| required
| T-Kategorie: Tumor
+
| fix: @code="tnmYSymbol", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmT"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
Zeile 552: Zeile 306:
 
|1..1
 
|1..1
 
|required
 
|required
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
+
|textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CD
 
|1..1
 
|required
 
|Code für die T-Kategorie
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| Art der Sicherung
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmCp"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|klinisch oder pathologisch
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|"c" oder "p", Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| C-Faktor
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmCFactor"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|C-Faktor (Certainty)
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
|m-Symbol  (Suffix)
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmMSymbol"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|m-Symbol: Multiplizität
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "m"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
|mi-Symbol  (Suffix)
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmMiSymbol"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
Zeile 810: Zeile 312:
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|value
 
|value
|CV
+
|BL
|1..1
 
|required
 
|mi-Symbol
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "mi"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
 
|1..1
 
|1..1
 
|required
 
|required
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
 
|
 
|
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
|auf Mucosa beschränkt
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmMucosaSymbol"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|Mucosa-Symbol
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|"m1", "m2" oder "m3"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
|auf Submucosa beschränkt
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmSubmucosaSymbol"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|Submucosa-Symbol
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|"sm1", "sm2" oder "sm3"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
  
 
|-
 
|-
Zeile 966: Zeile 324:
 
| 0..1
 
| 0..1
 
| optional
 
| optional
|  
+
| fix: @typeCode="SPRT"
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
  
 
|-
 
|-
Zeile 984: Zeile 333:
 
| 1..1
 
| 1..1
 
| required
 
| required
|  
+
| TNM r-Symbol (Präfix): Stadium eines Rezidivs
 
+
fix: @classCode="OBS", @moodCode="EVN"
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
  
 
|-
 
|-
Zeile 1.011: Zeile 343:
 
| 1..1
 
| 1..1
 
| required
 
| required
|N-Kategorie: Nodalstatus
+
| fix: @code="tnmRSymbol", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmN"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
Zeile 1.038: Zeile 352:
 
|1..1
 
|1..1
 
|required
 
|required
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
+
|textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CD
 
|1..1
 
|required
 
|Code für die N-Kategorie
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| Art der Sicherung
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmCp"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
Zeile 1.107: Zeile 358:
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|value
 
|value
|CV
+
|BL
 
|1..1
 
|1..1
 
|required
 
|required
|klinisch oder pathologisch
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
 
|
 
|
|1..1
 
|required
 
|"c" oder "p", Codesystem 2.16.840.1.113883.15.6
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| m-Symbol  (Suffix): Multiplizität
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmMSymbol"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|sn
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "sn"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| i (Suffix): ITC durch Immunhistochemie
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmI"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|"i+" oder "i-", Codesystem 2.16.840.1.113883.15.6
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| mol (Suffix): RT-PCR (ITC durch Molekularpathologie)
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmMol"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|"mol+" oder "mol-", Codesystem 2.16.840.1.113883.15.6
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|CR
 
|0..1
 
|optional
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| C-Faktor
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmCFactor"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|CV
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Code für Certainty Faktor, Codesystem 2.16.840.1.113883.15.6
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
  
 
|-
 
|-
Zeile 1.389: Zeile 370:
 
| 0..1
 
| 0..1
 
| optional
 
| optional
|  
+
| fix: @typeCode="SPRT"
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
  
 
|-
 
|-
Zeile 1.407: Zeile 379:
 
| 1..1
 
| 1..1
 
| required
 
| required
|  
+
| T: Tumor<br>
 
+
fix: @classCode="OBS", @moodCode="EVN"
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
  
 
|-
 
|-
Zeile 1.434: Zeile 389:
 
| 1..1
 
| 1..1
 
| required
 
| required
| M-Kategorie: Metastasen
+
| fix: @code="tnmT", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmM"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
  
 
|-
 
|-
Zeile 1.461: Zeile 398:
 
|1..1
 
|1..1
 
|required
 
|required
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
+
|textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
  
 
|-
 
|-
Zeile 1.470: Zeile 407:
 
|1..1
 
|1..1
 
|required
 
|required
|
+
|Code für die T-Kategorie<br>
 +
fix: @codeSystem="2.16.840.1.113883.15.6"
  
 
|-
 
|-
Zeile 1.483: Zeile 421:
 
|-
 
|-
 
|7
 
|7
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|qualifier
 
|qualifier
Zeile 1.497: Zeile 426:
 
|0..1
 
|0..1
 
|optional
 
|optional
|
+
|Art der Sicherung
  
 
|-
 
|-
| 6
+
| 8
 
|bgcolor="ff8888"| act
 
|bgcolor="ff8888"| act
 
| name
 
| name
Zeile 1.506: Zeile 435:
 
| 1..1
 
| 1..1
 
| required
 
| required
| Art der Sicherung
+
| fix: @code="tnmCp", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
  
 
|-
 
|-
|7
+
|8
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmCp"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|value
 
|value
Zeile 1.533: Zeile 444:
 
|1..1
 
|1..1
 
|required
 
|required
|
+
|klinisch oder pathologisch<br>
 +
fix: @codeSystem="2.16.840.1.113883.15.6"
  
 
|-
 
|-
|7
+
|9
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|@code
 
|@code
Zeile 1.542: Zeile 454:
 
|1..1
 
|1..1
 
|required
 
|required
|"c" oder "p", Codesystem 2.16.840.1.113883.15.6
+
|"c" oder "p"
  
 
|-
 
|-
 
|7
 
|7
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
|5
 
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|qualifier
 
|qualifier
Zeile 1.560: Zeile 463:
 
|0..1
 
|0..1
 
|optional
 
|optional
|
+
|C-Faktor (Certainty)
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| CV
 
| 1..1
 
| required
 
| sn, Feststellung durch Sentinel Node Biopsie
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|fix: "tnmSn"
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|sn
 
|CV
 
|1..1
 
|required
 
|Multiplizität
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"sn"
 
|
 
|1..1
 
|required
 
|fix
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| i (Suffix)
 
| CV
 
| 1..1
 
| required
 
| ITC durch Immunhistochemie
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmI"
 
|
 
|1..1
 
|required
 
|fix
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|i (ITC durch Immunhistochemie)
 
|CV
 
|1..1
 
|required
 
|
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|Code für Immunhistochemie ("i+" oder "i-")
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|
 
|CR
 
|0..1
 
|optional
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| name
 
| mol (Suffix)
 
| CV
 
| 1..1
 
| required
 
| ITC durch Molekularpathologie
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmMol"
 
|
 
|1..1
 
|required
 
|fix
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|mol (ITC durch Molekularpathologie)
 
|CV
 
|1..1
 
|required
 
|
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|Code für ITC durch Molekularpathologie ("mol+" oder "mol-")
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
|5
 
|bgcolor="ff8888"|act
 
|qualifier
 
|
 
|CR
 
|0..1
 
|optional
 
|
 
  
 
|-
 
|-
| 6
+
| 8
 
|bgcolor="ff8888"| act
 
|bgcolor="ff8888"| act
 
| name
 
| name
| C-Faktor
 
 
| CV
 
| CV
 
| 1..1
 
| 1..1
 
| required
 
| required
|  
+
| fix: @code="tnmCFactor", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmCFactor"
 
|
 
|1..1
 
|required
 
|fix
 
  
 
|-
 
|-
|7
+
|8
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|value
 
|value
|C-Faktor (Certainty)
 
 
|CV
 
|CV
 
|1..1
 
|1..1
 
|required
 
|required
|
+
|klinisch oder pathologisch<br>
 
+
fix: @codeSystem="2.16.840.1.113883.15.6"
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|Code für Certainty Faktor
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| S-Kategorie
 
| CD CWE
 
| 1..1
 
| required
 
| Serumtumormarker
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmS"
 
|
 
|1..1
 
|required
 
|fix
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|Code für die S-Kategorie
 
|CD
 
|1..1
 
|required
 
|
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| L-Status
 
| CD CWE
 
| 1..1
 
| required
 
| Lymphgefäßinvasion
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmL"
 
|
 
|1..1
 
|required
 
|fix
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|Code für den L-Status
 
|CD
 
|1..1
 
|required
 
|
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| V-Status
 
| CD CWE
 
| 1..1
 
| required
 
| Veneninvasion
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmV"
 
|
 
|1..1
 
|required
 
|fix
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|Code für den V-Status
 
|CD
 
|1..1
 
|required
 
|
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|
 
|1..1
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| Pn-Status
 
| CD CWE
 
| 1..1
 
| required
 
| Perineuralinvasion
 
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"tnmPn"
 
|
 
|1..1
 
|required
 
|fix
 
  
 
|-
 
|-
|7
+
|9
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|Code für den Pn-Status
 
|CD
 
|1..1
 
|required
 
|
 
 
 
|-
 
|7
 
 
|bgcolor="ff8888"|act
 
|bgcolor="ff8888"|act
 
|@code
 
|@code
Zeile 2.264: Zeile 492:
 
|required
 
|required
 
|Codesystem 2.16.840.1.113883.15.6
 
|Codesystem 2.16.840.1.113883.15.6
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "2.16.840.1.113883.15.6"
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| untersuchte Lymphknoten
 
| CD CWE
 
| 1..1
 
| required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"21894-1"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|"2.16.840.1.113883.6.1"
 
|
 
|1..1
 
|required
 
|fix: LOINC
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|
 
|PQ
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@value
 
|Anzahl untersuchter Lymphknoten
 
|
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@unit
 
|"1"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| befallene Lymphknoten
 
| CD CWE
 
| 1..1
 
| required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"21893-3"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|"2.16.840.1.113883.6.1"
 
|
 
|1..1
 
|required
 
|fix: LOINC
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|
 
|PQ
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@value
 
|Anzahl befallener Lymphknoten
 
|
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@unit
 
|"1"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| untersuchte Sentinel-Lymphknoten
 
| CD CWE
 
| 1..1
 
| required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"SentinelNodesExamined"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|
 
|PQ
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@value
 
|Anzahl untersuchter Sentinel-Lymphknoten
 
|
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@unit
 
|"1"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
| 4
 
|bgcolor="ffaaaa"| rel
 
| entryRelationship
 
|
 
|
 
| 0..1
 
| optional
 
|
 
 
|-
 
|5
 
|bgcolor="ffaaaa"| rel
 
|@typeCode
 
|
 
|1..1
 
|required
 
|fix: "SPRT"
 
 
|-
 
| 5
 
|bgcolor="ff8888"| act
 
| observation
 
|
 
|
 
| 1..1
 
| required
 
|
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @classCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "OBS"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| @moodCode
 
| CS CNE
 
| 1..1
 
| required
 
| fix: "EVN"
 
 
|-
 
| 6
 
|bgcolor="ff8888"| act
 
| code
 
| befallene Sentinel-Lymphknoten
 
| CD CWE
 
| 1..1
 
| required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@code
 
|"SentinelNodesPositive"
 
|
 
|1..1
 
|required
 
|fix
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@codeSystem
 
|
 
|1..1
 
|required
 
|fix: "1.2.276.0.76.3.1.131.1.5.1"
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|text
 
|ED
 
|1..1
 
|required
 
|textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert
 
 
|-
 
|6
 
|bgcolor="ff8888"|act
 
|value
 
|
 
|PQ
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@value
 
|Anzahl befallener Sentinel-Lymphknoten
 
|
 
|1..1
 
|required
 
|
 
 
|-
 
|7
 
|bgcolor="ff8888"|act
 
|@unit
 
|"1"
 
|
 
|1..1
 
|required
 
|fix
 
 
|}
 
  
 
===Beispiel 1===
 
===Beispiel 1===

Version vom 4. Juli 2013, 08:23 Uhr

Dieses Material ist Teil des Leitfadens Arztbrief 2.x.
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Entry: TNM-Klassifikation

Template ID 1.2.276.0.76.3.1.131.1.10.3.5 ?????
General Description Hiermit wird auf Entry-Level die Übermittlung von Tumordiagnosedaten (UICC TNM-Klassifikation) definiert.
LOINC Code Opt. Description
prov.67208-9 O R2

Darstellung der TNM-Klassifikation in HL7

Die Darstellung der TNM-Klassifikation in HL7 V3 erfolgt nach folgendem Schema. Es gibt eine zentrale Observation-Klasse, über welche das UICC-Stadium (als value) und/oder die Tumorformel (als Unterlement originalText dieses values) angegeben werden. Ist das UICC-Stadium nicht bekannt (z.B. weil bei einer pathologischen Befundung keine Angaben zu Metastasen existieren), wird im value der Haupt-Observation ein nullFlavor="NA" übermittelt. Die Tumorformel kann dennoch im originalText übermittelt werden.

Einzelangaben des werden ebenfalls in Observation-Klassen eingebunden, die über eine ActRelationShip-Klasse mit dem code SPRT mit der zentralen Observation-Klasse verbunden werden.

Diese Angaben sind (in Fachterminologie):

TNM-Symbol Bedeutung
a autoptisch erstmals festgestellt
y nach neoadjuvanter Therapie
r Beurteilung eines Rezidivs
T (Primär-)Tumor
N Nodus = Lymphknoten
M Metastasen
S Serumtumormarker (für bestimmte Tumorentitäten)
L Lymphgefäßinvasion
V Veneninvasion
Pn Perineuralinvasion
G Histopathologisches Grading
R Residualtumor


Weitere Angaben werden als qualifier für die jeweiligen values angegeben:

TNM-Symbol Bedeutung gültig für
c/p klinisch/pathologisch festgestellt T, N, M
C Certainty Factor T, N, M
m multipler Tumor (unquantifiziert) T
mi Mikrometastase (200<mi<2000 Mikrometer) N
mi Mikrokarzinom (mic<1000 Mikrometer) T, gilt nur für Mammakarzinome
sn Sentinel Nodes N
m1, m2, m3 auf Mukosa beschränkt, 1., 2. 3. Drittel T, gilt nur für gastrointestinale Karzinome
sm1, sm2, sm3 auf Submukosa beschränkt, 1., 2. 3. Drittel T, gilt nur für gastrointestinale Karzinome
(Lokalisationscode) Lokalisation der Metastasen M


Weiterhin existieren Zusatzangaben zu bestimmten Observations, die wiederum über eine ActRelationship als Observation angegeben werden:

TNM-Symbol Bedeutung gültig für
(kein) Multiplizität (Anzahl der Tumorherde, numerisch) T
i immunhistochemisch nachgewiesene isolierte Tumorzellen (ITC) N, M
mol molekularpathologisch nachgewiesene isolierte Tumorzellen (ITC) N, M
(kein) Anzahl entfernter und befallener Lymphknoten N

Isolierte Tumorzellen sind einzeln oder in Clustern von bis zu 200 Mikrometern Durchmesser vorkommende Tumorzellen, die bis auf das Melanom mit N0 kodiert werden. Mikrometastasen in Lymphknoten sind größer als 200 Mikrometer und kleiner als 2 mm, in aller Regel nur durch mikroskopische Untersuchung sichtbar.

TNM-Klassifikation

Abbildung: Darstellung der TNM-Klassifikation

Anmerkung: Die Begriffe "davor" bzw. "dahinter" in obiger Grafik geben an, ob dieser Qualifier in der Darstellung als Tumorformel vor oder hinter der entsprechenden Kategorie (T, N oder M) aufgeführt wird. In der XML-Darstellung spielt dies jedoch keine Rolle.

Zum einfacheren Verständnis kann dies auch in einer hierarchischen Form dargestellt werden. Die jeweils anwendbaren Qualifier sind dabei in Klammern angegeben:

+- UICC-Stadium, Tumorformel
  +- a
  +- y
  +- r
  +- T-Kategorie (c/p, C, m, mi, m1, m2, m3, sm1, sm2, sm3)
  |  +- Multiplizität
  +- N-Kategorie (c/p, C, mi, sn)
  |  +- Mikrometastase (200<mi<2000 Mikrometer), nur für p
  |  +- ITC durch Immunhistochemie nur für p
  |  +- ITC durch Molekularpathologie nur für p
  |  +- Anzahl der untersuchten und positiv bewerteten Knoten
  +- M-Kategorie (c/p, C, Lokalisationscodes)
  |  +- ITC durch Immunhistochemie
  |  +- ITC durch Molekularpathologie
  +- S (Serumtumormarker)
  +- L (Lymphgefäßinvasion)
  +- V (Veneninvasion)
  +- Pn (Perineuralscheideninvasion)
  +- G (histopathologisches Grading)
  +- R (Residualtumor)

Abbildung: Baumdarstellung der TNM-Klassifikation

Erläuterung

Lvl RIM Name DT Kard Conf Beschreibung
3 act observation 1..1 required fix: @classCode="OBS", @moodCode="EVN"
4 act templateId II 1..1 required fix: @root="1.2.276.0.76.3.1.131.1.10.3.5"
4 act id II 0..1 optional ID der diagnostischen Angabe
5 act @root 1..1 optional OID des sendenden Systems, um diagnostische Angaben eindeutig zu identifizieren
5 act @extension 1..1 optional ID der diagnostischen Angabe im sendenden System
4 act code CD CWE 1..1 required fix: @code="tnmStage", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
4 act text ED 1..1 required textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
4 act effectiveTime TS 0..1 optional Das Datum, an dem die Diagnose gestellt wurde
4 act value CD 1..1 required Code für das UICC-Stadium

fix: @codeSystem="2.16.840.1.113883.15.6"

5 act @code 1..1 required Codesystem 2.16.840.1.113883.15.6
4 rel entryRelationship 0..1 optional fix: @typeCode="SPRT"
5 act observation 1..1 required TNM a-Symbol (Präfix): Stadium bei Autopsie festgestellt

fix: @classCode="OBS", @moodCode="EVN"

6 act code CD CWE 1..1 required fix: @code="tnmASymbol", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
6 act text ED 1..1 required textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
6 act value BL 1..1 required
4 rel entryRelationship 0..1 optional fix: @typeCode="SPRT"
5 act observation 1..1 required TNM y-Symbol (Präfix): Stadium nach neoadjuvanter Therapie

fix: @classCode="OBS", @moodCode="EVN"

6 act code CD CWE 1..1 required fix: @code="tnmYSymbol", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
6 act text ED 1..1 required textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
6 act value BL 1..1 required
4 rel entryRelationship 0..1 optional fix: @typeCode="SPRT"
5 act observation 1..1 required TNM r-Symbol (Präfix): Stadium eines Rezidivs

fix: @classCode="OBS", @moodCode="EVN"

6 act code CD CWE 1..1 required fix: @code="tnmRSymbol", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
6 act text ED 1..1 required textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
6 act value BL 1..1 required
4 rel entryRelationship 0..1 optional fix: @typeCode="SPRT"
5 act observation 1..1 required T: Tumor

fix: @classCode="OBS", @moodCode="EVN"

6 act code CD CWE 1..1 required fix: @code="tnmT", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
6 act text ED 1..1 required textliche Beschreibung, i.d.R. vom sendenden System automatisch generiert
6 act value CD 1..1 required Code für die T-Kategorie

fix: @codeSystem="2.16.840.1.113883.15.6"

7 act @code 1..1 required Codesystem 2.16.840.1.113883.15.6
7 act qualifier CR 0..1 optional Art der Sicherung
8 act name CV 1..1 required fix: @code="tnmCp", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
8 act value CV 1..1 required klinisch oder pathologisch

fix: @codeSystem="2.16.840.1.113883.15.6"

9 act @code 1..1 required "c" oder "p"
7 act qualifier CR 0..1 optional C-Faktor (Certainty)
8 act name CV 1..1 required fix: @code="tnmCFactor", @codeSystem="1.2.276.0.76.3.1.131.1.5.1"
8 act value CV 1..1 required klinisch oder pathologisch

fix: @codeSystem="2.16.840.1.113883.15.6"

9 act @code 1..1 required Codesystem 2.16.840.1.113883.15.6

Beispiel 1

<entry>
  <observation classCode="OBS" moodCode="EVN">
	<templateId root='' />
	<id root='' extension=''' />
	<code code='' codeSystem='' />
	...
	<value xsi:type="CD"
		codeSystem="2.16.840.1.113883.15.8"
		code="IV">
		<originalText>
			Tumorformel: T1 N2 ......
		</originalText>

	<!-- Einzelteile der Tumorformel -->
	<entryRelationship typeCode="SPRT">
		<observation moodCode="EVN" classCode="OBS">
			<!-- T-Code -->
			<value xsi:type="CD" code="T1" 
				codeSystem="2.16.840.1.113883.15.8" codeSystemName=" tnm5"/>
				<qualifier>
					<name code="341" codeSystem="2.16.840.1.113883.3.7.1.0"/>
					<value code="C2" codeSystem="1.2.276.0.76.5.341"/>
				</qualifier>
			</value>
		</observation>
	</entryRelationship>

	<entryRelationship typeCode="SPRT">
		<observation moodCode="EVN" classCode="OBS">
			<!-- N-Code -->
			<value xsi:type="CD" code="N2" 
				codeSystem="2.16.840.1.113883.15.8" codeSystemName="tnm5"/>
			</value>
		</observation>
	</entryRelationship>

	<entryRelationship typeCode="SPRT">
		<observation moodCode="EVN" classCode="OBS">
			<!-- M-Code -->
			<value xsi:type="CD" code="M0" 
				displayName="Fernmetastasen nicht vorhanden"
				codeSystem="2.16.840.1.113883.15.8" codeSystemName="tnm5"/>
			</value>
		</observation>
	</entryRelationship>

  </observation>
</entry>

Beispiel 2

Das folgende Beispiel stellt das Maximum der möglichen Angaben dar, wohl wissend, dass dies aus medizinisch-fachlicher Sicht nicht korrekt ist.

<observation classCode="OBS" moodCode="EVN">
	<templateId root="1.2.276.0.76.3.1.131.1.10.3.5"/>
	<id extension="tnm12345" 
		root="1.2.276.0.76.3.1.131.1.4.3.9999.9999.999909"/>
	<code code="tnmStage" 
		codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
	<text>
		Tumorklassifikation vom 26.03.2011: ayr UICC IV
	</text>
	<effectiveTime value="20110326"/>
	<value xsi:type="CD" code="IV" 
		codeSystem="2.16.840.1.113883.15.6">
		<qualifier>
			<name code="tnmASymbol" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<value xsi:type="CD" code="a" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</qualifier>
		<qualifier>
			<name code="tnmYSymbol" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<value xsi:type="CD" code="y" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</qualifier>
		<qualifier>
			<name code="tnmRSymbol" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<value xsi:type="CD" code="r" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</qualifier>
	</value>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmT" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				 pT3amC4
			</text>
			<value xsi:type="CD" code="T3a" 
				codeSystem="2.16.840.1.113883.15.6">
				<qualifier>
					<name code="tnmCp" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="p" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmCFactor" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="C4" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmMSymbol" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="m" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
			</value>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmN" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				 pN3(sn)(i+)(mol+)C5
			</text>
			<value xsi:type="CD" code="N3" 
				codeSystem="2.16.840.1.113883.15.6">
				<qualifier>
					<name code="tnmCp" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="p" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmSn" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="sn" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmI" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="i+" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmMol" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="mol+" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmCFactor" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="C5" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
			</value>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmM" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				cM1(sn)(i+)(mol+)C2
			</text>
			<value xsi:type="CD" code="M1" 
				codeSystem="2.16.840.1.113883.15.6">
				<qualifier>
					<name code="tnmCp" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="c" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmSn" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="sn" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmI" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="i+" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmMol" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="mol+" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
				<qualifier>
					<name code="tnmCFactor" 
						codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
					<value xsi:type="CD" code="C2" 
						codeSystem="2.16.840.1.113883.15.6"/>
				</qualifier>
			</value>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmS" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				 S2
			</text>
			<value xsi:type="CD" code="S2" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmL" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				 L1
			</text>
			<value xsi:type="CD" code="L1" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmV" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				 V1
			</text>
			<value xsi:type="CD" code="V1" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="tnmPn" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				 PnX
			</text>
			<value xsi:type="CD" code="PnX" 
				codeSystem="2.16.840.1.113883.15.6"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="21894-1" 
				codeSystem="2.16.840.1.113883.6.1"/>
			<text>
				Lymphknoten untersucht: 18
			</text>
			<value xsi:type="PQ" value="18" unit="1"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="21893-3" 
				codeSystem="2.16.840.1.113883.6.1"/>
			<text>
				Lymphknoten befallen: 13
			</text>
			<value xsi:type="PQ" value="13" unit="1"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="SentinelNodesExamined" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				Sentinel-Lymphknoten untersucht: 5
			</text>
			<value xsi:type="PQ" value="5" unit="1"/>
		</observation>
	</entryRelationship>
	<entryRelationship typeCode="COMP">
		<observation classCode="OBS" moodCode="EVN">
			<code code="SentinelNodesPositive" 
				codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
			<text>
				Sentinel-Lymphknoten befallen: 4
			</text>
			<value xsi:type="PQ" value="4" unit="1"/>
		</observation>
	</entryRelationship>
</observation>


verwendete Terminologie

Tumore

Bekannte T-Kategorien (ohne Darstellung möglicher Zusätze). Die Beschreibung variiert je nach Entität. Der Code soll nur in Zusammenhang mit der Art der Tumorerkrankung übermittelt werden, da die Kodes mit unterschiedlichen Bedeutungen belegt sind (z.B. T1 entspricht 2-3 cm oder 2-4 cm).

UICC
Code Description Bedeutung 5. 6. 7.
Ta X X X
Tis Carcinoma in situ Nicht invasiv X X X
T0 No evidence of primary tumour Kein Primärtumor nach¬weisbar X X
T1 X X X
T1mic Microinvasion X X X
T1a X X X
T1a1 X X X
T1a2 X X X
T1b X X X
T1b1 X X X
T1b2 X X X
T1c X X X
T1d X
T2 X X X
T2a X X X
T2a1 X
T2a2 X
T2b X X X
T2c X X X
T2d X
T3 X X X
T3a X X X
T3b X X X
T3c X X X
T3d X X
T4 X X X
T4a X X X
T4b X X X
T4c X X X
T4d X X X
T4e X
TX Primary tumour cannot be assessed Stadium des Primärtumors kann nicht nachgewiesen werden.

Tabelle 20: (T) Tumor-Codes
Value Set (OID 1.2.276.0.76.11.1)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Nodes (Knoten)

Der Code für die Lymphknotenbeteiligung soll nur in Zusammenhang mit der Art der Tumorerkrankung (ICD-O-Klassifikation) übermittelt werden.

UICC
Code Description Bedeutung Entität 5. 6. 7.
N0 No regional lymph node metastasis Kein Lymphknotenbefall alle X X X
N1 X X X
N1mi lymph node micrometastasis alle X X??
N1mi Bilateral regional lymph node metastasis Vulva X X  ????
N1a alle X X X
N1b X X X
N1b1 X ???
N1b2 X ???
N1b3 X ???
N1b4 X ???
N1c X X ???
N2 X X X
N2a X X X
N2b X X X
N2c X X X
N3 X X X
N3a X X X
N3b X X X
N3c X X
NX Regional lymph nodes cannot be assessed Lymphknotenbefall unbekannt X X X

Tabelle 21: (N) Lymphknoten-Codes
Value Set (OID 1.2.276.0.76.11.2)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Metastasen

Der Code zur Beurteilung von Fernmetastasen soll nur in Zusammenhang mit der Art der Tumorerkrankung übermittelt werden

UICC
Code Description Bedeutung Entität 5. 6. 7.
M0 No distant metastasis Fernmetastasen nicht vorhanden (für p nicht anwendbar) alle X X X
M1 Distant metastasis Fernmetastasen vorhanden alle X X X
M1a nur Ösophagus und Prostata X X X
M1b nur Ösophagus und Prostata X X X
M1c X X X
M1d X
M1e X
MX Distant metastasis cannot be assessed (für p nicht anwendbar) alle X X X

Tabelle 22: (M) Metastasen-Codes
Value Set (OID 1.2.276.0.76.11.3)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Residualtumor

identisch mit R-Klassifikation

Code Description Bedeutung
R0 No residual tumour kein Residualtumor
R1 Microscopic residual tumour nur mikroskopisch nachweisbarer Residualtumor
R2 Macroscopic residual tumour makroskopischer Residualtumor und
R2a - mikroskopisch nicht bestätigt
R2b - mikroskopisch bestätigt
RX Presence of residual tumour cannot be assessed Unbekannt

Tabelle 23: Residualtumor-Codes
Value Set (OID 1.2.276.0.76.11.4)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Stadiengruppierung nach UICC

UICC
Code Beschreibung Bedeutung 5. 6. 7.
okk TX, N0, M0 X X X
0 Carcinoma in situ Tis, N0, M0 X X X
0a X X X
0is X X X
I X X
IA T1, N0, M0 X X X
IA1 X X X
IA2 X X X
IB T2, N0, M0 X X X
IB1 X X X
IB2 X X X
IC X X X
II X X X
IIA T1, N1, M0 X X X
IIA1 X
IIA2 X
IIB T2, N1, M0 X X X
IIC T3, N0, M0 X X X
III X X X
IIIA T1, N2, M0 X X X
T2, N2, M0
T3, N1,2, M0
IIIB T4, jedes N, M0 X X X
jedes T, N3, M0
IIIC X X X
IS X X X
IV jedes T, jedes N, M1 X X X
IVA X X X
IVB X X X
IVC X X X
nicht definiert X X X
nicht empfohlen X X

Tabelle 24: Stadiengruppierung16
Value Set (OID 1.2.276.0.76.11.5)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Veneninvasion

Code Description Bedeutung
V0 no venous invasion keine Veneninvasion
V1 microscopic venous invasion mikroskopische Veneninvasion
V2 macroscopic venous invasion makroskopische Veneninvasion
VX venous invasion cannot be assessed Veneninvasion nicht feststellbar

Tabelle 25: Veneninvasion-Codes
Value Set (OID 1.2.276.0.76.11.6)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Lymphsysteminvasion

Code Description Bedeutung
L0 no lymphatic invasion keine Lymphsysteminvasion
L1 lymphatic invasion Lymphsysteminvasion
LX lmphatic invasion cannot be assessed Lymphsysteminvasion nicht fest¬stellbar

Tabelle 26: Lymphsysteminvasion-Codes
Value Set (OID 1.2.276.0.76.11.7)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Neuralscheideninvasion

Code Description Bedeutung
Pn0 no perineural invasion keine perineurale Invasion
Pn1 Perineural invasion perineurale Invasion
PnX unknown Unbekannt

Tabelle 27: Neuralscheideninvasion-Codes
Value Set (OID 1.2.276.0.76.11.8)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Qualifier

Code Description Bedeutung
c Assessment according to clinical criteria Beurteilung nach klinischen Kriterien
p Assessment according to the pathological results nach dem pathologischen Befund
r TNM result of recurrent tumor TNM-Befund für Rezidivtumor
y Classification of initial multimodal therapy Klassifikation nach initialer multi¬modaler Therapie
a Primary classification at autopsy autoptisch erstmals festgestellt
C Certainty Factor Sicherheitsfaktor der Klassifikationselemente
m multiple Tumors (not quantified) multipler Tumor (unquantifiziert)
mi Lymph node micro-metastasis Mikrometastase
mic Micro carcinoma Mikrokarzinom, gilt nur für Mammakarzinome
sn Sentinel Nodes Schildwächterlymphknoten
m1-3 restricted to mucosa auf Mukosa beschränkt, 1., 2. 3. Drittel, gilt nur für gastrointestinale Karzinome
sm1-3 restricted to submucosa auf Submukosa beschränkt, 1., 2. 3. Drittel, gilt nur für gastrointestinale Karzinome
Lok. Localisation of distant metastases Lokalisation der Metastasen

Tabelle 28: TNM-Qualifier
Value Set (OID 1.2.276.0.76.11.9)
UICC 5. Auflage (OID 2.16.840.1.113883.15.8)
UICC 6. Auflage (OID 2.16.840.1.113883.15.7)
UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

Certainty

Code Description Nachweis
C1 Evidence from standard diagnostic means (e.g., inspection, palpation, and standard radiography, intra¬luminal endoscopy for tumours of certain organs) Nachweis durch diagnostische Standardmethoden (Inspektion, Palpation, einfache Röntgenaufnahmen)
C2 Evidence obtained by special diag¬nostic means (e.g., radiographic imaging in special projections, tomography, computerized tomo¬graphy \[CT\], ultrasonography, lympho¬graphy, angiography; scinti¬graphy; magnetic resonance imaging \[MRI\]; endoscopy, biopsy, and cytology) Nachweis durch spezielle klinische diagnostische Methoden einschließlich Computertomogramm, Magnet-Resonanz-Tomographie
C3 Evidence from surgical exploration, including biopsy and cytology Nachweis durch Operation, einschließlich Biopsie und Zytologie
C4 Evidence of the extent of disease following definitive surgery and pathological examination of the resected specimen Nachweis durch operative Behandlung mit pathologischer Untersuchung der entnommenen Gewebeteile
C5 Evidence from autopsy Nachweis durch Autopsie

Tabelle 29: Certainty Factor-Codes (OID 1.2.276.0.76.5.341)

Lokalisation von Metastasen

Die Lokalisation von Metastasen wird ebenfalls als Qualifier in der entsprechenden observation untergebracht.

Code Description Bedeutung
PUL Pulmonary Pulmonal Lungenmetastase
OSS Osseous Ossär Knochenmetastase
HEP Hepatic Hepatisch Lebermetastase
BRA Brain Cerebral Hirnmetastase
LYM Lymph Nodes Lymphonodulär Lymphknotenmetastase
OTH Others Andere Andere Metastase
MAR Bone Marrow Medullär Knochenmarkmetastase
PLE Pleura Pleural RippenfellMetastase
ADR Adrenals Adrenal Nebennierenmetastase
SKI Skin dermal Hautmetastase

Tabelle 30: Metastasen-Lokalisation-Codes (OID 1.2.276.0.76.5.401)