Ann-Arbor-Stadium-Entry (Template)
(Teildokument von Übermittlung onkologischer Daten)
Dieses Material ist Teil des Leitfadens Übermittlung onkologischer Daten.
|
Entry: Ann Arbor Stadium
| Template ID | 1.2.276.0.76.3.1.131.1.10.3.6 | |
| General Description | In diesem Entry wird das Ann Arbor Stadium übermittelt. | |
 |
TODO: offizielles Score-Modell verwenden, Abgleich mit Diagnoseleitfaden |
Abbildung: Ann Arbor Stadium
| Lvl | RIM | Name | Desc | DT | Kard | Conf | Beschreibung |
|---|---|---|---|---|---|---|---|
| 3 | act | observation | 1..1 | required | |||
| 4 | act | @classCode | "OBS" | CS CNE | 1..1 | required | fix |
| 4 | act | @moodCode | "EVN" | CS CNE | 1..1 | required | fix |
| 4 | act | templateId | Ann Arbor Stadium | II | 1..1 | required | |
| 5 | act | @root | "1.2.276.0.76.3.1.131.1.10.3.6" | 1..1 | required | fix | |
| 4 | act | id | ID der diagnostischen Angabe | II | 0..1 | optional | |
| 5 | act | @root | OID für diagnostische Angaben | 1..1 | optional | OID des sendenden System, um diagnostische Angaben eindeutig zu identifizieren | |
| 5 | act | @extension | ID der diagnostischen Angabe im sendenden System | 1..1 | optional | ||
| 4 | act | code | Ann Arbor Stadium | CD CWE | 1..1 | required | |
| 5 | act | @code | "AnnArborStage" | 1..1 | required | fix | |
| 5 | act | @codeSystem | "1.2.276.0.76.3.1.131.1.5.1" | 1..1 | required | fix: DKG-Labels | |
| 4 | act | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert |
| 4 | act | effectiveTime | Zeitpunkt der Feststellung | TS | 0..1 | optional | Das Datum, an dem die Diagnose gestellt wurde |
| 4 | act | value | Code für das Ann Arbor Stadium | CD | 1..1 | required | |
| 5 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 1.2.276.0.76.5.405 | |
| 5 | act | @codeSystem | "1.2.276.0.76.5.405" | 1..1 | required | fix | |
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | "COMP" | 1..1 | required | fix | |
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | "OBS" | CS CNE | 1..1 | required | fix |
| 6 | act | @moodCode | "EVN" | CS CNE | 1..1 | required | fix |
| 6 | act | code | Ann Arbor B-Symptome | CD CWE | 1..1 | required | |
| 7 | act | @code | "AnnArborBSymptoms" | 1..1 | required | fix | |
| 7 | act | @codeSystem | "1.2.276.0.76.3.1.131.1.5.1" | 1..1 | required | fix: DKG-Labels | |
| 6 | act | value | CD | 1..1 | required | ||
| 7 | act | @code | Code für Ann Arbor B-Symptome | 1..1 | required | Codesystem 1.2.276.0.76.5.416 | |
| 7 | act | @codeSystem | "1.2.276.0.76.5.416" | 1..1 | required | fix | |
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | "COMP" | 1..1 | required | fix | |
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | "OBS" | CS CNE | 1..1 | required | fix |
| 6 | act | @moodCode | "EVN" | CS CNE | 1..1 | required | fix |
| 6 | act | code | Ann Arbor extranodaler Befall | CD CWE | 1..1 | required | |
| 7 | act | @code | "AnnArborExtranodal" | 1..1 | required | fix | |
| 7 | act | @codeSystem | "1.2.276.0.76.3.1.131.1.5.1" | 1..1 | required | fix: DKG-Labels | |
| 6 | act | value | CD | 1..1 | required | ||
| 7 | act | @code | Code für Ann Arbor extranodalen Befall | 1..1 | required | Codesystem 1.2.276.0.76.5.417 | |
| 7 | act | @codeSystem | "1.2.276.0.76.5.417" | 1..1 | required | fix | |
| 7 | act | qualifier | CR | 0..* | optional | ||
| 8 | act | name | Angabe zum Organbefall | CV | 1..1 | required | |
| 9 | act | @code | Organ | 1..1 | required | Value Set 1.2.276.0.76.3.1.131.1.11.5 | |
| 9 | act | @codeSystem | "2.16.840.1.113883.6.96" | 1..1 | required | fix: SNOMED CT | |
| 8 | act | value | Ja/Nein-Angabe bzw. unbekannt | CV | 1..1 | required | Es wird entweder die Kombination der Attribute code und codeSystem oder das Attribut nullFlavor übermittelt |
| 9 | act | @code | "true" oder "false" | 0..1 | M | Codesystem 1.2.276.0.76.3.1.131.1.5.61 | |
| 9 | act | @codeSystem | "1.2.276.0.76.3.1.131.1.5.61" | 0..1 | M | fix | |
| 9 | act | @nullFlavor | "UNK" | 0..1 | M | fix |
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.2.276.0.76.3.1.131.1.10.3.6"/>
<id extension="1234017"
root="1.2.276.0.76.3.1.131.1.4.3.9999.9999.999919"/>
<code code="AnnArborStage"
codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
<text>
Ann Arbor III/BS
befallene Organe: Milz, Lunge, Leber, Pleura, Nebenniere, Haut
</text>
<effectiveTime value="20110326"/>
<value xsi:type="CD" code="III"
codeSystem="1.2.276.0.76.5.405"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="AnnArborBSymptoms"
codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
<value xsi:type="CD" code="B"
codeSystem="1.2.276.0.76.5.416"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="AnnArborExtranodal"
codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>
<value xsi:type="CD" code="S" codeSystem="1.2.276.0.76.5.417">
<qualifier>
<name code="127230005"
codeSystem="2.16.840.1.113883.6.96"/>
<value xsi:type="CD" code="true"
codeSystem="1.2.276.0.76.3.1.131.1.5.61"/>
</qualifier>
<qualifier>
...
</qualifier>
...
</value>
</observation>
</entryRelationship>
</observation>
