TNM-Klassifikation-Entry (Template)
(Teildokument von Arztbrief 2.x)
Slang (Diskussion | Beiträge) (→Erläuterung) |
Slang (Diskussion | Beiträge) (→Erläuterung) |
||
| Zeile 486: | Zeile 486: | ||
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: " | + | |fix: "SPRT" |
|- | |- | ||
| Zeile 496: | Zeile 495: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| observation | | observation | ||
| − | | | + | | |
| 1..1 | | 1..1 | ||
| required | | required | ||
| Zeile 514: | Zeile 513: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
|- | |- | ||
| Zeile 524: | Zeile 522: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| code | | code | ||
| − | |||
| CD CWE | | CD CWE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | Tumor | + | | T-Kategorie: Tumor |
|- | |- | ||
| Zeile 534: | Zeile 531: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmT" |
|- | |- | ||
| Zeile 544: | Zeile 540: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 554: | Zeile 549: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
|- | |- | ||
| Zeile 564: | Zeile 558: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CD | |CD | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | | | + | |Code für die T-Kategorie |
|- | |- | ||
| Zeile 574: | Zeile 567: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
| Zeile 584: | Zeile 576: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 594: | Zeile 585: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 604: | Zeile 594: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | | Art der Sicherung |
|- | |- | ||
| Zeile 614: | Zeile 603: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmCp" |
|- | |- | ||
| Zeile 624: | Zeile 612: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 634: | Zeile 621: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | | | + | |klinisch oder pathologisch |
|- | |- | ||
| Zeile 644: | Zeile 630: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |Codesystem 2.16.840.1.113883.15.6 | + | |"c" oder "p", Codesystem 2.16.840.1.113883.15.6 |
|- | |- | ||
| Zeile 654: | Zeile 639: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 664: | Zeile 648: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 674: | Zeile 657: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | | C-Faktor |
|- | |- | ||
| Zeile 684: | Zeile 666: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmCFactor" |
|- | |- | ||
| Zeile 694: | Zeile 675: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 704: | Zeile 684: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | | | + | |C-Faktor (Certainty) |
|- | |- | ||
| Zeile 714: | Zeile 693: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
| Zeile 724: | Zeile 702: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 734: | Zeile 711: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 744: | Zeile 720: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | |m-Symbol (Suffix) |
|- | |- | ||
| Zeile 754: | Zeile 729: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmMSymbol" |
|- | |- | ||
| Zeile 764: | Zeile 738: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 774: | Zeile 747: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |Multiplizität | + | |m-Symbol: Multiplizität |
|- | |- | ||
| Zeile 784: | Zeile 756: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "m" |
|- | |- | ||
| Zeile 794: | Zeile 765: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 804: | Zeile 774: | ||
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
| entryRelationship | | entryRelationship | ||
| − | |||
| | | | ||
| 0..1 | | 0..1 | ||
| Zeile 814: | Zeile 783: | ||
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
|- | |- | ||
| Zeile 824: | Zeile 792: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| observation | | observation | ||
| − | |||
| | | | ||
| 1..1 | | 1..1 | ||
| Zeile 834: | Zeile 801: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
|- | |- | ||
| Zeile 844: | Zeile 810: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
|- | |- | ||
| Zeile 854: | Zeile 819: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| code | | code | ||
| − | |||
| CD CWE | | CD CWE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | Nodalstatus | + | |N-Kategorie: Nodalstatus |
|- | |- | ||
| Zeile 864: | Zeile 828: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmN" |
|- | |- | ||
| Zeile 874: | Zeile 837: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 884: | Zeile 846: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
|- | |- | ||
| Zeile 894: | Zeile 855: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CD | |CD | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | | | + | |Code für die N-Kategorie |
|- | |- | ||
| Zeile 904: | Zeile 864: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
| Zeile 914: | Zeile 873: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 924: | Zeile 882: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 934: | Zeile 891: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | | Art der Sicherung |
|- | |- | ||
| Zeile 944: | Zeile 900: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmCp" |
|- | |- | ||
| Zeile 954: | Zeile 909: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 964: | Zeile 918: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | | | + | |klinisch oder pathologisch |
|- | |- | ||
| Zeile 974: | Zeile 927: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |Codesystem 2.16.840.1.113883.15.6 | + | |"c" oder "p", Codesystem 2.16.840.1.113883.15.6 |
|- | |- | ||
| Zeile 984: | Zeile 936: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 994: | Zeile 945: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 1.004: | Zeile 954: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | | m-Symbol (Suffix): Multiplizität |
|- | |- | ||
| Zeile 1.014: | Zeile 963: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmMSymbol" |
|- | |- | ||
| Zeile 1.024: | Zeile 972: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 1.034: | Zeile 981: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | | | + | |sn |
|- | |- | ||
| Zeile 1.044: | Zeile 990: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "sn" |
|- | |- | ||
| Zeile 1.054: | Zeile 999: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 1.064: | Zeile 1.008: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 1.074: | Zeile 1.017: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | ITC durch Immunhistochemie | + | | i (Suffix): ITC durch Immunhistochemie |
|- | |- | ||
| Zeile 1.084: | Zeile 1.026: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmI" |
|- | |- | ||
| Zeile 1.094: | Zeile 1.035: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 1.104: | Zeile 1.044: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
| Zeile 1.114: | Zeile 1.053: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |Codesystem 2.16.840.1.113883.15.6 | + | |"i+" oder "i-", Codesystem 2.16.840.1.113883.15.6 |
|- | |- | ||
| Zeile 1.124: | Zeile 1.062: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 1.134: | Zeile 1.071: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
| − | |||
|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 1.144: | Zeile 1.080: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | RT-PCR | + | | mol (Suffix): RT-PCR (ITC durch Molekularpathologie) |
|- | |- | ||
| Zeile 1.154: | Zeile 1.089: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmMol" |
|- | |- | ||
| Zeile 1.164: | Zeile 1.098: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
|- | |- | ||
| Zeile 1.174: | Zeile 1.107: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
| − | |||
|CV | |CV | ||
|1..1 | |1..1 | ||
| Zeile 1.184: | Zeile 1.116: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |Codesystem 2.16.840.1.113883.15.6 | + | |"mol+" oder "mol-", Codesystem 2.16.840.1.113883.15.6 |
|- | |- | ||
| Zeile 1.194: | Zeile 1.125: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
| − | |||
| | | | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 1.204: | Zeile 1.134: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
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|CR | |CR | ||
|0..1 | |0..1 | ||
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | | C-Faktor |
|- | |- | ||
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmCFactor" |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
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|CV | |CV | ||
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|@code | |@code | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |Codesystem 2.16.840.1.113883.15.6 | + | |Code für Certainty Faktor, Codesystem 2.16.840.1.113883.15.6 |
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|required | |required | ||
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|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
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|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
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| observation | | observation | ||
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| code | | code | ||
| − | |||
| CD CWE | | CD CWE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | Metastasen | + | | M-Kategorie: Metastasen |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmM" |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
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|CD | |CD | ||
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|@code | |@code | ||
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|qualifier | |qualifier | ||
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|CR | |CR | ||
|0..1 | |0..1 | ||
| Zeile 1.404: | Zeile 1.314: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | | + | | Art der Sicherung |
|- | |- | ||
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmCp" |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
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|CV | |CV | ||
|1..1 | |1..1 | ||
| Zeile 1.444: | Zeile 1.350: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |Codesystem 2.16.840.1.113883.15.6 | + | |"c" oder "p", Codesystem 2.16.840.1.113883.15.6 |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
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|0..1 | |0..1 | ||
| Zeile 1.474: | Zeile 1.377: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| name | | name | ||
| − | |||
| CV | | CV | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | Feststellung durch Sentinel Node Biopsie | + | | sn, Feststellung durch Sentinel Node Biopsie |
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|@code | |@code | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "tnmSn" |
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
|- | |- | ||
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|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
|- | |- | ||
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
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|1..1 | |1..1 | ||
| Zeile 1.974: | Zeile 1.854: | ||
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
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|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
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| Zeile 2.014: | Zeile 1.892: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
|- | |- | ||
| Zeile 2.024: | Zeile 1.901: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
|- | |- | ||
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
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|1..1 | |1..1 | ||
| Zeile 2.094: | Zeile 1.967: | ||
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 2.114: | Zeile 1.986: | ||
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
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| Zeile 2.134: | Zeile 2.005: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
|- | |- | ||
| Zeile 2.144: | Zeile 2.014: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
|- | |- | ||
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix: | + | |fix: "1.2.276.0.76.3.1.131.1.5.1" |
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|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|text | |text | ||
| − | |||
|ED | |ED | ||
|1..1 | |1..1 | ||
|required | |required | ||
| − | |i.d.R. vom sendenden System automatisch generiert | + | |textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert |
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| Zeile 2.204: | Zeile 2.071: | ||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|@code | |@code | ||
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|1..1 | |1..1 | ||
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|@codeSystem | |@codeSystem | ||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "2.16.840.1.113883.15.6" |
|- | |- | ||
| Zeile 2.234: | Zeile 2.099: | ||
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
|@typeCode | |@typeCode | ||
| − | |||
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|1..1 | |1..1 | ||
|required | |required | ||
| − | |fix | + | |fix: "SPRT" |
|- | |- | ||
| Zeile 2.254: | Zeile 2.118: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @classCode | | @classCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "OBS" |
|- | |- | ||
| Zeile 2.264: | Zeile 2.127: | ||
|bgcolor="ff8888"| act | |bgcolor="ff8888"| act | ||
| @moodCode | | @moodCode | ||
| − | |||
| CS CNE | | CS CNE | ||
| 1..1 | | 1..1 | ||
| required | | required | ||
| − | | fix | + | | fix: "EVN" |
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Version vom 4. Juli 2013, 07:30 Uhr
Dieses Material ist Teil des Leitfadens Arztbrief 2.x.
|
Inhaltsverzeichnis
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.
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
 |
Prüfung und Reduktion der Darstellung, bspw. kodierte Datentypen! |
| Lvl | RIM | Name | DT | Kard | Conf | Beschreibung | |
|---|---|---|---|---|---|---|---|
| 3 | act | observation | 1..1 | required | |||
| 4 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 4 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 4 | act | templateId | II | 1..1 | required | TNM-Klassifikation | |
| 5 | act | @root | 1..1 | required | fix: "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 | ||
| 5 | act | @code | 1..1 | required | fix: "tnmStage" | ||
| 5 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 4 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, 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 | |
| 5 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 5 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | TNM a-Symbol (Präfix): Stadium bei Autopsie festgestellt | |
| 7 | act | @code | 1..1 | required | fix: "tnmASymbol" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | Code für das a-Symbol | |
| 7 | act | @code | 1..1 | required | fix: "a" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | TNM y-Symbol (Präfix): Stadium nach neoadjuvanter Therapie | |
| 7 | act | @code | 1..1 | required | fix: "tnmYSymbol" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | Code für das y-Symbol | |
| 7 | act | @code | 1..1 | required | fix: "y" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | TNM r-Symbol (Präfix): Stadium eines Rezidivs | |
| 7 | act | @code | 1..1 | required | fix: "tnmRSymbol" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | Code für das r-Symbol | |
| 7 | act | @code | 1..1 | required | fix: "r" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | CD CWE | 1..1 | required | T-Kategorie: Tumor | |
| 7 | act | @code | 1..1 | required | fix: "tnmT" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | CD | 1..1 | required | Code für die T-Kategorie | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | Art der Sicherung | |
| 7 | act | @code | 1..1 | required | fix: "tnmCp" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | klinisch oder pathologisch | |
| 7 | act | @code | 1..1 | required | "c" oder "p", Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | C-Faktor | |
| 7 | act | @code | 1..1 | required | fix: "tnmCFactor" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | C-Faktor (Certainty) | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | m-Symbol (Suffix) | |
| 7 | act | @code | 1..1 | required | fix: "tnmMSymbol" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | m-Symbol: Multiplizität | |
| 7 | act | @code | 1..1 | required | fix: "m" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | CD CWE | 1..1 | required | N-Kategorie: Nodalstatus | |
| 7 | act | @code | 1..1 | required | fix: "tnmN" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | CD | 1..1 | required | Code für die N-Kategorie | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | Art der Sicherung | |
| 7 | act | @code | 1..1 | required | fix: "tnmCp" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | klinisch oder pathologisch | |
| 7 | act | @code | 1..1 | required | "c" oder "p", Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | m-Symbol (Suffix): Multiplizität | |
| 7 | act | @code | 1..1 | required | fix: "tnmMSymbol" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | sn | |
| 7 | act | @code | 1..1 | required | fix: "sn" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | i (Suffix): ITC durch Immunhistochemie | |
| 7 | act | @code | 1..1 | required | fix: "tnmI" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | ||
| 7 | act | @code | 1..1 | required | "i+" oder "i-", Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | mol (Suffix): RT-PCR (ITC durch Molekularpathologie) | |
| 7 | act | @code | 1..1 | required | fix: "tnmMol" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | ||
| 7 | act | @code | 1..1 | required | "mol+" oder "mol-", Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | C-Faktor | |
| 7 | act | @code | 1..1 | required | fix: "tnmCFactor" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | ||
| 7 | act | @code | 1..1 | required | Code für Certainty Faktor, Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | CD CWE | 1..1 | required | M-Kategorie: Metastasen | |
| 7 | act | @code | 1..1 | required | fix: "tnmM" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | CD | 1..1 | required | ||
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | Art der Sicherung | |
| 7 | act | @code | 1..1 | required | fix: "tnmCp" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | CV | 1..1 | required | ||
| 7 | act | @code | 1..1 | required | "c" oder "p", Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | CV | 1..1 | required | sn, Feststellung durch Sentinel Node Biopsie | |
| 7 | act | @code | 1..1 | required | fix: "tnmSn" | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | sn | CV | 1..1 | required | Multiplizität |
| 7 | act | @code | "sn" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | i (Suffix) | CV | 1..1 | required | ITC durch Immunhistochemie |
| 7 | act | @code | "tnmI" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | i (ITC durch 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 | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 5 | act | qualifier | CR | 0..1 | optional | ||
| 6 | act | name | mol (Suffix) | CV | 1..1 | required | ITC durch Molekularpathologie |
| 7 | act | @code | "tnmMol" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | value | mol (ITC durch Molekularpathologie) | CV | 1..1 | required | |
| 7 | act | @code | Code für ITC durch Molekularpathologie ("mol+" oder "mol-") | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | |
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 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..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 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 | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | S-Kategorie | CD CWE | 1..1 | required | Serumtumormarker |
| 7 | act | @code | "tnmS" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für die S-Kategorie | CD | 1..1 | required | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | L-Status | CD CWE | 1..1 | required | Lymphgefäßinvasion |
| 7 | act | @code | "tnmL" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für den L-Status | CD | 1..1 | required | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | V-Status | CD CWE | 1..1 | required | Veneninvasion |
| 7 | act | @code | "tnmV" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für den V-Status | CD | 1..1 | required | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | Pn-Status | CD CWE | 1..1 | required | Perineuralinvasion |
| 7 | act | @code | "tnmPn" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, i.d.R. vom sendenden System automatisch generiert | |
| 6 | act | value | Code für den Pn-Status | CD | 1..1 | required | |
| 7 | act | @code | 1..1 | required | Codesystem 2.16.840.1.113883.15.6 | ||
| 7 | act | @codeSystem | 1..1 | required | fix: "2.16.840.1.113883.15.6" | ||
| 4 | rel | entryRelationship | 0..1 | optional | |||
| 5 | rel | @typeCode | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 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 | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, 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 | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 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 | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, 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 | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | untersuchte Sentinel-Lymphknoten | CD CWE | 1..1 | required | |
| 7 | act | @code | "SentinelNodesExamined" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, 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 | 1..1 | required | fix: "SPRT" | ||
| 5 | act | observation | 1..1 | required | |||
| 6 | act | @classCode | CS CNE | 1..1 | required | fix: "OBS" | |
| 6 | act | @moodCode | CS CNE | 1..1 | required | fix: "EVN" | |
| 6 | act | code | befallene Sentinel-Lymphknoten | CD CWE | 1..1 | required | |
| 7 | act | @code | "SentinelNodesPositive" | 1..1 | required | fix | |
| 7 | act | @codeSystem | 1..1 | required | fix: "1.2.276.0.76.3.1.131.1.5.1" | ||
| 6 | act | text | ED | 1..1 | required | textliche Beschreibung des codierten Inhalts der Observation, 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 |
Beispiel 1
|
|
Abgleich der beiden Beispiele! |
<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
 |
Die TNM-Klassifikation gemäß UICC wird insgesamt als Codeystem aufgefasst. Somit haben die verschiedenen Tabellen die gleiche OID, die dann in der Übermittlung anzugeben ist. Die einfachste Möglichkeit, damit umzugehen, ist die Definition eines Value Sets mit Festlegung der jeweils möglichen Werte. Darüber hinaus werden für diese Tabellen dann angegeben, welche Werte daraus aus den entsprechenden UICC Ausgaben (Auflagen) entstammen und somit über das jeweilige konkrete Kodiersystem angegeben werden können. |
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)
