TNM-Klassifikation-Entry (Template)
(Teildokument von Übermittlung onkologischer Daten)
Foemig (Diskussion | Beiträge) (verschoben, muss aber noch korrigiert werden) |
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| − | [[Kategorie:CDA Entry Level Template]] | + | [[Kategorie:CDA Entry Level Template|TNM-Klassifikation]] |
Version vom 13. Februar 2013, 17:27 Uhr
Dieses Material ist Teil des Leitfadens Übermittlung onkologischer Daten.
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Abgleich mit dem Diagnoseleitfaden und dem TNM-Entry-Template in cdaab2! |
Entry: TNM-Klassifikation
| Template ID | 1.2.276.0.76.3.1.131.1.10.3.5 | |
| General Description | TNM-Klassifikation | |
In einer Diagnostik-Sektion sind mehrere Entries des Typs TNM-Klassifikation zulässig, beispielsweise um sowohl die klinische als auch die pathologische Beurteilung zu übermitteln.
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TODO: Abgleich mit dem Diagnoseleitfaden ist erforderlich!! |
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TODO: Diagramm ergänzen
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| 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 | TNM-Klassifikation | II | 1..1 | required | ||
| 5 | act | @root | "1.2.276.0.76.3.1.131.1.10.3.5" | 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 | CD CWE | 1..1 | required | |||
| 5 | act | @code | "tnmStage" | 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 UICC-Stadium | CD | 1..1 | required | ||
| 5 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 5 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | TNM a-Symbol | CV | 1..1 | required | Stadium bei Autopsie festgestellt | |
| 7 | act | @code | "tnmASymbol" | 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 | Code für das a-Symbol | CV | 1..1 | required | ||
| 7 | act | @code | "a" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | TNM y-Symbol | CV | 1..1 | required | Stadium nach neoadjuvanter Therapie | |
| 7 | act | @code | "tnmYSymbol" | 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 | Code für das y-Symbol | CV | 1..1 | required | ||
| 7 | act | @code | "y" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | TNM r-Symbol | CV | 1..1 | required | Stadium eines Rezidivs | |
| 7 | act | @code | "tnmRSymbol" | 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 | Code für das r-Symbol | CV | 1..1 | required | ||
| 7 | act | @code | "r" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | T-Stadium | CD CWE | 1..1 | required | Tumor | |
| 7 | act | @code | "tnmT" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das T-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | Art der Sicherung | CV | 1..1 | required | ||
| 7 | act | @code | "tnmCp" | 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 | klinisch oder pathologisch | CV | 1..1 | required | ||
| 7 | act | @code | "c" oder "p" | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | C-Faktor | CV | 1..1 | required | ||
| 7 | act | @code | "tnmCFactor" | 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 | C-Faktor (Certainty) | CV | 1..1 | required | ||
| 7 | act | @code | Code für Certainty Faktor | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | m-Symbol | CV | 1..1 | required | ||
| 7 | act | @code | "tnmMSymbol" | 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 | m-Symbol | CV | 1..1 | required | Multiplizität | |
| 7 | act | @code | "m" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | N-Stadium | CD CWE | 1..1 | required | Nodalstatus | |
| 7 | act | @code | "tnmN" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das N-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | Art der Sicherung | CV | 1..1 | required | ||
| 7 | act | @code | "tnmCp" | 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 | klinisch oder pathologisch | CV | 1..1 | required | ||
| 7 | act | @code | "c" oder "p" | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | SN | CV | 1..1 | required | Feststellung durch Sentinel Node Biopsie | |
| 7 | act | @code | "tnmSn" | 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 | SN | CV | 1..1 | required | Multiplizität | |
| 7 | act | @code | "SN" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | i | CV | 1..1 | required | Immunhistochemie | |
| 7 | act | @code | "tnmI" | 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 | i (Immunhistochemie) | CV | 1..1 | required | ||
| 7 | act | @code | Code für Immunhistochemie ("i+" oder "i-") | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | mol | CV | 1..1 | required | RT-PCR | |
| 7 | act | @code | "tnmMol" | 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 | mol (RT-PCR) | CV | 1..1 | required | ||
| 7 | act | @code | Code für RT-PCR ("mol+" oder "mol-") | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | C-Faktor | CV | 1..1 | required | ||
| 7 | act | @code | "tnmCFactor" | 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 | C-Faktor (Certainty) | CV | 1..1 | required | ||
| 7 | act | @code | Code für Certainty Faktor | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | M-Stadium | CD CWE | 1..1 | required | Metastasen | |
| 7 | act | @code | "tnmM" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das M-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | Art der Sicherung | CV | 1..1 | required | ||
| 7 | act | @code | "tnmCp" | 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 | klinisch oder pathologisch | CV | 1..1 | required | ||
| 7 | act | @code | "c" oder "p" | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | elm | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | SN | CV | 1..1 | required | Feststellung durch Sentinel Node Biopsie | |
| 7 | act | @code | "tnmSn" | 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 | SN | CV | 1..1 | required | Multiplizität | |
| 7 | act | @code | "SN" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | i | CV | 1..1 | required | Immunhistochemie | |
| 7 | act | @code | "tnmI" | 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 | i (Immunhistochemie) | CV | 1..1 | required | ||
| 7 | act | @code | Code für Immunhistochemie ("i+" oder "i-") | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | mol | CV | 1..1 | required | RT-PCR | |
| 7 | act | @code | "tnmMol" | 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 | mol (RT-PCR) | CV | 1..1 | required | ||
| 7 | act | @code | Code für RT-PCR ("mol+" oder "mol-") | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 1..1 | required | fix | ||
| 5 | act | qualifier | CR | 0..1 | optional | |||
| 6 | act | name | C-Faktor | CV | 1..1 | required | ||
| 7 | act | @code | "tnmCFactor" | 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 | C-Faktor (Certainty) | CV | 1..1 | required | ||
| 7 | act | @code | Code für Certainty Faktor | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | S-Stadium | CD CWE | 1..1 | required | Serumtumormarker | |
| 7 | act | @code | "tnmS" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das S-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | L-Stadium | CD CWE | 1..1 | required | Lymphgefäßinvasion | |
| 7 | act | @code | "tnmL" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das L-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | V-Stadium | CD CWE | 1..1 | required | Veneninvasion | |
| 7 | act | @code | "tnmV" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das V-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | Pn-Stadium | CD CWE | 1..1 | required | Perineuralinvasion | |
| 7 | act | @code | "tnmPn" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für das Pn-Stadium | CD | 1..1 | required | ||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.15.6" | 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 | untersuchte Lymphknoten | CD CWE | 1..1 | required | ||
| 7 | act | @code | "21894-1" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.6.1" | 1..1 | required | fix: LOINC | ||
| 6 | act | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | PQ | 1..1 | required | |||
| 7 | act | @value | Anzahl untersuchter Lymphknoten | 1..1 | required | |||
| 7 | act | @unit | "1" | 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 | befallene Lymphknoten | CD CWE | 1..1 | required | ||
| 7 | act | @code | "21893-3" | 1..1 | required | fix | ||
| 7 | act | @codeSystem | "2.16.840.1.113883.6.1" | 1..1 | required | fix: LOINC | ||
| 6 | act | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | PQ | 1..1 | required | |||
| 7 | act | @value | Anzahl befallener Lymphknoten | 1..1 | required | |||
| 7 | act | @unit | "1" | 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 | untersuchte Sentinel-Lymphknoten | CD CWE | 1..1 | required | ||
| 7 | act | @code | "SentinelNodesExamined" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | PQ | 1..1 | required | |||
| 7 | act | @value | Anzahl untersuchter Sentinel-Lymphknoten | 1..1 | required | |||
| 7 | act | @unit | "1" | 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 | befallene Sentinel-Lymphknoten | CD CWE | 1..1 | required | ||
| 7 | act | @code | "SentinelNodesPositive" | 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 | text | textliche Beschreibung des codierten Inhalts der Observation | ED | 1..1 | required | i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | PQ | 1..1 | required | |||
| 7 | act | @value | Anzahl befallener Sentinel-Lymphknoten | 1..1 | required | |||
| 7 | act | @unit | "1" | 1..1 | required | fix |
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>
