Elston-Ellis-Score-Entry (Template)
Slang (Diskussion | Beiträge) (→Beispiel) |
Foemig (Diskussion | Beiträge) K |
||
(3 dazwischenliegende Versionen von 2 Benutzern werden nicht angezeigt) | |||
Zeile 2: | Zeile 2: | ||
==Elston-Ellis-Score Entry (Template) (Nottingham-Grading)== | ==Elston-Ellis-Score Entry (Template) (Nottingham-Grading)== | ||
+ | |||
+ | {{AlertBox| | ||
+ | Zu diesem Score-System existiert ein fertiger Value Set in cdaonk Assessment scales [[cdaonk:Assessment_Scales_Entry_(Template)#Malignit.C3.A4tsgrading_invasiver_Mammakarzinome_nach_Elston_und_Ellis_.28Nottingham_Grading.29|Elston-Ellis]]. Abgleich erforderlich G.H. | ||
+ | }} | ||
{| class="hl7table" | {| class="hl7table" | ||
Zeile 49: | Zeile 53: | ||
|1..1 | |1..1 | ||
|M | |M | ||
− | |Elston-Ellis-Score (Nottingham) | + | |'''Elston-Ellis-Score (Nottingham)''' |
|- | |- | ||
|2 | |2 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|code | |code | ||
Zeile 70: | Zeile 65: | ||
|- | |- | ||
− | | | + | |2 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
Zeile 79: | Zeile 74: | ||
|- | |- | ||
− | | | + | | 2 |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
| entryRelationship | | entryRelationship | ||
Zeile 94: | Zeile 80: | ||
| 0..1 | | 0..1 | ||
| O | | O | ||
− | | | + | | '''1. Komponente''' |
|- | |- | ||
− | | | + | |3 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|observation | |observation | ||
Zeile 106: | Zeile 92: | ||
|- | |- | ||
− | | | + | |4 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|code | |code | ||
Zeile 115: | Zeile 101: | ||
|- | |- | ||
− | | | + | |4 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
Zeile 124: | Zeile 110: | ||
|- | |- | ||
− | | | + | |2 |
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
| entryRelationship | | entryRelationship | ||
Zeile 130: | Zeile 116: | ||
| 0..1 | | 0..1 | ||
| O | | O | ||
− | | | + | | '''2. Komponente''' |
|- | |- | ||
− | | | + | |3 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|observation | |observation | ||
Zeile 142: | Zeile 128: | ||
|- | |- | ||
− | | | + | |4 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|code | |code | ||
Zeile 151: | Zeile 137: | ||
|- | |- | ||
− | | | + | |4 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
Zeile 160: | Zeile 146: | ||
|- | |- | ||
− | | | + | | 2 |
|bgcolor="ffaaaa"| rel | |bgcolor="ffaaaa"| rel | ||
| entryRelationship | | entryRelationship | ||
Zeile 166: | Zeile 152: | ||
| 0..1 | | 0..1 | ||
| O | | O | ||
− | | | + | | '''3. Komponente''' |
|- | |- | ||
− | | | + | |3 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|observation | |observation | ||
Zeile 178: | Zeile 164: | ||
|- | |- | ||
− | | | + | |4 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|code | |code | ||
Zeile 187: | Zeile 173: | ||
|- | |- | ||
− | | | + | |4 |
|bgcolor="ff8888"|act | |bgcolor="ff8888"|act | ||
|value | |value | ||
Zeile 203: | Zeile 189: | ||
'''Code System OID: todo.codesystem.xxy004''' | '''Code System OID: todo.codesystem.xxy004''' | ||
+ | |||
+ | Code: | ||
+ | @code="44648-4" | ||
+ | @codeSystem="2.16.840.1.113883.6.1" | ||
+ | |||
{| class="hl7table" | {| class="hl7table" | ||
Zeile 231: | Zeile 222: | ||
'''Code System OID: 2.16.840.1.113883.6.96''' | '''Code System OID: 2.16.840.1.113883.6.96''' | ||
+ | |||
+ | in LOINC: Tubulusbildung=44644-3, 2.16.840.1.113883.6.1 | ||
{| class="hl7table" | {| class="hl7table" | ||
|- | |- | ||
− | ! Code | + | ! Score |
+ | ! Snomed CT Code | ||
! Bedeutung (Kurztext) | ! Bedeutung (Kurztext) | ||
! Bemerkung | ! Bemerkung | ||
|- | |- | ||
− | ||369778004||> 75%||Breast tubule formation: Majority of tumor >75% | + | | 1 ||369778004||> 75%||Breast tubule formation: Majority of tumor >75% |
|- | |- | ||
− | ||369779007||10-75%||Breast tubule formation: Moderate 10% to 75% | + | | 2 ||369779007||10-75%||Breast tubule formation: Moderate 10% to 75% |
|- | |- | ||
− | ||369780005||< 10%||Breast tubule formation: Minimal <10% | + | | 3 ||369780005||< 10%||Breast tubule formation: Minimal <10% |
|} | |} | ||
Zeile 251: | Zeile 245: | ||
'''Code System OID: 2.16.840.1.113883.6.96''' | '''Code System OID: 2.16.840.1.113883.6.96''' | ||
+ | |||
+ | in LOINC: Kernpolymorphie=44645-0, 2.16.840.1.113883.6.1 | ||
{| class="hl7table" | {| class="hl7table" | ||
|- | |- | ||
+ | ! Score | ||
! Code | ! Code | ||
! Bedeutung (Kurztext) | ! Bedeutung (Kurztext) | ||
Zeile 259: | Zeile 256: | ||
|- | |- | ||
− | ||384735004||gering||Nuclear pleomorphism: small regular nuclei | + | | 1 ||384735004||gering||Nuclear pleomorphism: small regular nuclei |
|- | |- | ||
− | ||384737007||mäßig||Nuclear pleomorphism: moderate increase in size, etc | + | | 2 ||384737007||mäßig||Nuclear pleomorphism: moderate increase in size, etc. |
|- | |- | ||
− | ||384738002||stark||Nuclear pleomorphism: marked variation in size, nucleoli, chromatin clumping, etc | + | | 3 ||384738002||stark||Nuclear pleomorphism: marked variation in size, nucleoli, chromatin clumping, etc. |
|} | |} | ||
Zeile 273: | Zeile 270: | ||
'''Code System OID: todo.codesystem.xxy007''' | '''Code System OID: todo.codesystem.xxy007''' | ||
+ | |||
+ | in LOONC: Mitoserate*=44650-0, 2.16.840.1.113883.6.1 | ||
{| class="hl7table" | {| class="hl7table" | ||
|- | |- | ||
− | ! | + | ! Score |
! Bedeutung (Kurztext) | ! Bedeutung (Kurztext) | ||
! Bemerkung | ! Bemerkung | ||
|- | |- | ||
− | ||1|| | + | ||1||z.B. SFZ 25: 0-10 / SFZ 20: 0-8|| |
+ | |- | ||
+ | ||2|| z.B. SFZ 25: 11-20 / SFZ 20: 9-16|| | ||
+ | |- | ||
+ | ||3||z.B. SFZ 25: > 20 / SFZ 20: > 16|| | ||
+ | |||
+ | |} | ||
+ | |||
+ | |||
+ | Value Set (OID TODO - Code System 1.2.276.0.76.5.336??): | ||
+ | |||
+ | {| class="hl7table" | ||
+ | !ScoreItem!!Code!!CodeSystem!!Kriterien!!Value | ||
+ | |- | ||
+ | |Mitoserate*||44650-0||2.16.840.1.113883.6.1||0-5/10 HPF||1 | ||
+ | |- | ||
+ | |Mitoserate*||44650-0||2.16.840.1.113883.6.1||6-11/10 HPF||2 | ||
|- | |- | ||
− | || | + | |Mitoserate*||44650-0||2.16.840.1.113883.6.1||>11/10 HPF||3 |
|- | |- | ||
− | | | + | |} |
+ | |||
+ | * ... die Schwellwerte der Mitoserate sind abhängig vom verwendeten Objektiv (Gesichtsfeldgröße). Die hier angegebenen Werte gelten für Gesichtsfelddurchmesser von 0,44-0,45 mm. | ||
+ | |||
+ | ===unklar / doppelt ???=== | ||
+ | |||
+ | Aus den drei Scorewerten wird ein Summenscore für den Malignitätsgrad gebildet. | ||
+ | {| class="hl7table" | ||
+ | !InterpretationCode!!ObservationRange!!Interpretation | ||
+ | |- | ||
+ | |MG1||3-5||grade 1 (gut differenziert) | ||
+ | |- | ||
+ | |MG2||6-7||grade 2 (mäßig differenziert) | ||
+ | |- | ||
+ | |MG3||8-9||grade 3 (schlecht differenziert) | ||
+ | |- | ||
|} | |} | ||
Zeile 329: | Zeile 359: | ||
[[Kategorie:cdaab2|Elston-Ellis-Score]] | [[Kategorie:cdaab2|Elston-Ellis-Score]] | ||
[[Kategorie:CDA Entry Level Template|Elston-Ellis-Score]] | [[Kategorie:CDA Entry Level Template|Elston-Ellis-Score]] | ||
+ | [[Kategorie:Scores|Elston-Ellis-Score]] |
Aktuelle Version vom 28. November 2013, 09:48 Uhr
Dieses Material ist Teil des Leitfadens Arztbrief 2.x.
|
Inhaltsverzeichnis
Elston-Ellis-Score Entry (Template) (Nottingham-Grading)
Zu diesem Score-System existiert ein fertiger Value Set in cdaonk Assessment scales Elston-Ellis. Abgleich erforderlich G.H. |
Template-Metadaten | |
Template-Typ | Entry |
Template ID | <OID für das Template> |
generischeres Template | Assessment Scales |
genutzte Templates | |
nutzende Templates | Grading |
abgeleitete Templates | |
Generelle Beschreibung | Diese Seite beschreibt die Darstellung des Elston-Ellis-Scores |
allg. Erläuterung | Scores_und_Assessments |
Verhältnis zu IHE | neu |
Ballotierungsstatus | in Arbeit |
Erweiterbarkeit | geschlossen |
Übersicht
Die Elemente werden, sofern spezialisiert/abweichend vom übergeordneten Template, hier als Walk Through beschrieben:
Lvl | RIM | Name | DT | Kard | Conf | Beschreibung |
---|---|---|---|---|---|---|
1 | act | observation | 1..1 | M | Elston-Ellis-Score (Nottingham) | |
2 | act | code | CD CWE | 1..1 | F | @code: "396293007", @codeSystem: 2.16.840.1.113883.6.96 |
2 | act | value | CD CWE | 1..1 | M | Wert aus dem Scoresystem. Value Set: todo.valueset.xxy004 |
2 | rel | entryRelationship | 0..1 | O | 1. Komponente | |
3 | act | observation | 1..1 | O | Tubulusbildung (Tubule formation score) | |
4 | act | code | CD CWE | 1..1 | F | @code: "371470008", @codeSystem: 2.16.840.1.113883.6.96 |
4 | act | value | CD CWE | 1..1 | M | Value Set: todo.valueset.xxy005 |
2 | rel | entryRelationship | 0..1 | O | 2. Komponente | |
3 | act | observation | 1..1 | O | Kernpolymorphie (Nuclear pleomorphism score) | |
4 | act | code | CD CWE | 1..1 | F | @code: "371471007", @codeSystem: 2.16.840.1.113883.6.96 |
4 | act | value | CD CWE | 1..1 | M | Value Set: todo.valueset.xxy006 |
2 | rel | entryRelationship | 0..1 | O | 3. Komponente | |
3 | act | observation | 1..1 | O | Mitoserate (Number of mitoses per 10 high power fields) | |
4 | act | code | CD CWE | 1..1 | F | @code: "406094009", @codeSystem: 2.16.840.1.113883.6.96 |
4 | act | value | CD CWE | 1..1 | M | Value Set: todo.valueset.xxy007 |
Value Sets
Elston-Ellis-Score
Value Set OID: todo.valueset.xxy004
Code System OID: todo.codesystem.xxy004
Code: @code="44648-4" @codeSystem="2.16.840.1.113883.6.1"
Code | Bedeutung (Kurztext) | Bemerkung |
---|---|---|
3 | Elston-Ellis-Score 3 | |
4 | Elston-Ellis-Score 4 | |
5 | Elston-Ellis-Score 5 | |
6 | Elston-Ellis-Score 6 | |
7 | Elston-Ellis-Score 7 | |
8 | Elston-Ellis-Score 8 | |
9 | Elston-Ellis-Score 9 |
Tubulusbildung
Value Set OID: todo.valueset.xxy005
Code System OID: 2.16.840.1.113883.6.96
in LOINC: Tubulusbildung=44644-3, 2.16.840.1.113883.6.1
Score | Snomed CT Code | Bedeutung (Kurztext) | Bemerkung |
---|---|---|---|
1 | 369778004 | > 75% | Breast tubule formation: Majority of tumor >75% |
2 | 369779007 | 10-75% | Breast tubule formation: Moderate 10% to 75% |
3 | 369780005 | < 10% | Breast tubule formation: Minimal <10% |
Kernpolymorphie
Value Set OID: todo.valueset.xxy006
Code System OID: 2.16.840.1.113883.6.96
in LOINC: Kernpolymorphie=44645-0, 2.16.840.1.113883.6.1
Score | Code | Bedeutung (Kurztext) | Bemerkung |
---|---|---|---|
1 | 384735004 | gering | Nuclear pleomorphism: small regular nuclei |
2 | 384737007 | mäßig | Nuclear pleomorphism: moderate increase in size, etc. |
3 | 384738002 | stark | Nuclear pleomorphism: marked variation in size, nucleoli, chromatin clumping, etc. |
Mitoserate
Die Grundlage dieses Scores (Anzahl Mitosen/10 HPF) ist von der Beobachtungssituation des Pathologen abhängig (Größe des Gesichtsfeldes). Daher wird hier nicht die hierauf fixierte Codierung aus SNOMED-CT verwendet.
Value Set OID: todo.valueset.xxy007
Code System OID: todo.codesystem.xxy007
in LOONC: Mitoserate*=44650-0, 2.16.840.1.113883.6.1
Score | Bedeutung (Kurztext) | Bemerkung |
---|---|---|
1 | z.B. SFZ 25: 0-10 / SFZ 20: 0-8 | |
2 | z.B. SFZ 25: 11-20 / SFZ 20: 9-16 | |
3 | z.B. SFZ 25: > 20 / SFZ 20: > 16 |
Value Set (OID TODO - Code System 1.2.276.0.76.5.336??):
ScoreItem | Code | CodeSystem | Kriterien | Value |
---|---|---|---|---|
Mitoserate* | 44650-0 | 2.16.840.1.113883.6.1 | 0-5/10 HPF | 1 |
Mitoserate* | 44650-0 | 2.16.840.1.113883.6.1 | 6-11/10 HPF | 2 |
Mitoserate* | 44650-0 | 2.16.840.1.113883.6.1 | >11/10 HPF | 3 |
- ... die Schwellwerte der Mitoserate sind abhängig vom verwendeten Objektiv (Gesichtsfeldgröße). Die hier angegebenen Werte gelten für Gesichtsfelddurchmesser von 0,44-0,45 mm.
unklar / doppelt ???
Aus den drei Scorewerten wird ein Summenscore für den Malignitätsgrad gebildet.
InterpretationCode | ObservationRange | Interpretation |
---|---|---|
MG1 | 3-5 | grade 1 (gut differenziert) |
MG2 | 6-7 | grade 2 (mäßig differenziert) |
MG3 | 8-9 | grade 3 (schlecht differenziert) |
Beispiel
<observation moodCode='EVN' classCode='OBS'>
<templateID root='' />
<id root='' extension='' />
<code code='396293007' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='7' codeSystem='todo.codesystem.xxy004'/>
<entryRelationship typeCode='COMP'>
<observation moodCode='EVN' classCode='OBS'>
<code code='371470008' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='369780005' codeSystem='2.16.840.1.113883.6.96'/>
</observation>
</entryRelationship>
<entryRelationship typeCode='COMP'>
<observation moodCode='EVN' classCode='OBS'>
<code code='371471007' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='384737007' codeSystem='2.16.840.1.113883.6.96'/>
</observation>
</entryRelationship>
<entryRelationship typeCode='COMP'>
<observation moodCode='EVN' classCode='OBS'>
<code code='406094009' codeSystem='2.16.840.1.113883.6.96' />
<statusCode code='completed'/>
<value xsi:type='CD' code='2' codeSystem='todo.codesystem.xxy007'/>
</observation>
</entryRelationship>
</observation>