TNM-Klassifikation-Entry (Template)

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Tabelle 10: Codes für Tumordiagnosen (OID 1.2.276.0.76.5.334)
 
Tabelle 10: Codes für Tumordiagnosen (OID 1.2.276.0.76.5.334)
  
−
===Beispiel===
+
===Erläuterung===
 +
 
 +
{{WorkBox|
 +
Prüfung und Reduktion der Darstellung, bspw. kodierte Datentypen!
 +
}}
 +
 
 +
 
 +
{| class="hl7table"
 +
! Lvl
 +
! RIM
 +
! Name
 +
! Desc
 +
! DT
 +
! Kard
 +
! Conf
 +
! Beschreibung
 +
 
 +
|-
 +
| 3
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ff8888"| act
 +
| templateId
 +
| TNM-Klassifikation
 +
| II
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| @root
 +
| "1.2.276.0.76.3.1.131.1.10.3.5"
 +
|
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ff8888"| act
 +
| id
 +
| ID der diagnostischen Angabe
 +
| II
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|@root
 +
|OID für diagnostische Angaben
 +
|
 +
|1..1
 +
|optional
 +
|OID des sendenden System, um diagnostische Angaben eindeutig zu identifizieren
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|@extension
 +
|ID der diagnostischen Angabe im sendenden System
 +
|
 +
|1..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ff8888"| act
 +
| code
 +
|
 +
| CD CWE
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmStage"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|4
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ff8888"| act
 +
| effectiveTime
 +
| Zeitpunkt der Feststellung
 +
| TS
 +
| 0..1
 +
| optional
 +
| Das Datum, an dem die Diagnose gestellt wurde
 +
 
 +
|-
 +
|4
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das UICC-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| TNM a-Symbol
 +
| CV
 +
| 1..1
 +
| required
 +
| Stadium bei Autopsie festgestellt
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmASymbol"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das a-Symbol
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"a"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| TNM y-Symbol
 +
| CV
 +
| 1..1
 +
| required
 +
| Stadium nach neoadjuvanter Therapie
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmYSymbol"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das y-Symbol
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"y"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| TNM r-Symbol
 +
| CV
 +
| 1..1
 +
| required
 +
| Stadium eines Rezidivs
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmRSymbol"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das r-Symbol
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"r"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| T-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Tumor
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmT"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das T-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| Art der Sicherung
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmCp"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|klinisch oder pathologisch
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"c" oder "p"
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| C-Faktor
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmCFactor"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|C-Faktor (Certainty)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für Certainty Faktor
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| m-Symbol
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmMSymbol"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|m-Symbol
 +
|CV
 +
|1..1
 +
|required
 +
|Multiplizität
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"m"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| N-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Nodalstatus
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmN"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das N-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| Art der Sicherung
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmCp"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|klinisch oder pathologisch
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"c" oder "p"
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| SN
 +
| CV
 +
| 1..1
 +
| required
 +
| Feststellung durch Sentinel Node Biopsie
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmSn"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|SN
 +
|CV
 +
|1..1
 +
|required
 +
|Multiplizität
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"SN"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| i
 +
| CV
 +
| 1..1
 +
| required
 +
| Immunhistochemie
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmI"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|i (Immunhistochemie)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für Immunhistochemie ("i+" oder "i-")
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| mol
 +
| CV
 +
| 1..1
 +
| required
 +
| RT-PCR
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmMol"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|mol (RT-PCR)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für RT-PCR ("mol+" oder "mol-")
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| C-Faktor
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmCFactor"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|C-Faktor (Certainty)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für Certainty Faktor
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| M-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Metastasen
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmM"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das M-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| Art der Sicherung
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmCp"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|klinisch oder pathologisch
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"c" oder "p"
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| SN
 +
| CV
 +
| 1..1
 +
| required
 +
| Feststellung durch Sentinel Node Biopsie
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmSn"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|SN
 +
|CV
 +
|1..1
 +
|required
 +
|Multiplizität
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"SN"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| i
 +
| CV
 +
| 1..1
 +
| required
 +
| Immunhistochemie
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmI"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|i (Immunhistochemie)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für Immunhistochemie ("i+" oder "i-")
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| mol
 +
| CV
 +
| 1..1
 +
| required
 +
| RT-PCR
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmMol"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|mol (RT-PCR)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für RT-PCR ("mol+" oder "mol-")
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|5
 +
|bgcolor="ff8888"|act
 +
|qualifier
 +
|
 +
|CR
 +
|0..1
 +
|optional
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| name
 +
| C-Faktor
 +
| CV
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmCFactor"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|C-Faktor (Certainty)
 +
|CV
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|Code für Certainty Faktor
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| S-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Serumtumormarker
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmS"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das S-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| L-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Lymphgefäßinvasion
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmL"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das L-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| V-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Veneninvasion
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmV"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das V-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| Pn-Stadium
 +
| CD CWE
 +
| 1..1
 +
| required
 +
| Perineuralinvasion
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"tnmPn"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|Code für das Pn-Stadium
 +
|CD
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|eigentlicher Code
 +
|
 +
|1..1
 +
|required
 +
|Codesystem 2.16.840.1.113883.15.6
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.15.6"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| untersuchte Lymphknoten
 +
| CD CWE
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"21894-1"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.6.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: LOINC
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|
 +
|PQ
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@value
 +
|Anzahl untersuchter Lymphknoten
 +
|
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@unit
 +
|"1"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| befallene Lymphknoten
 +
| CD CWE
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"21893-3"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"2.16.840.1.113883.6.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: LOINC
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|
 +
|PQ
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@value
 +
|Anzahl befallener Lymphknoten
 +
|
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@unit
 +
|"1"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| untersuchte Sentinel-Lymphknoten
 +
| CD CWE
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"SentinelNodesExamined"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|
 +
|PQ
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@value
 +
|Anzahl untersuchter Sentinel-Lymphknoten
 +
|
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@unit
 +
|"1"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 4
 +
|bgcolor="ffaaaa"| rel
 +
| entryRelationship
 +
|
 +
|
 +
| 0..1
 +
| optional
 +
|
 +
 
 +
|-
 +
|5
 +
|bgcolor="ffaaaa"| rel
 +
|@typeCode
 +
|"COMP"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
| 5
 +
|bgcolor="ff8888"| act
 +
| observation
 +
|
 +
|
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @classCode
 +
| "OBS"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| @moodCode
 +
| "EVN"
 +
| CS CNE
 +
| 1..1
 +
| required
 +
| fix
 +
 
 +
|-
 +
| 6
 +
|bgcolor="ff8888"| act
 +
| code
 +
| befallene Sentinel-Lymphknoten
 +
| CD CWE
 +
| 1..1
 +
| required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@code
 +
|"SentinelNodesPositive"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@codeSystem
 +
|"1.2.276.0.76.3.1.131.1.5.1"
 +
|
 +
|1..1
 +
|required
 +
|fix: DKG-Labels
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|text
 +
|textliche Beschreibung des codierten Inhalts der Observation
 +
|ED
 +
|1..1
 +
|required
 +
|i.d.R. vom sendenden System automatisch generiert
 +
 
 +
|-
 +
|6
 +
|bgcolor="ff8888"|act
 +
|value
 +
|
 +
|PQ
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@value
 +
|Anzahl befallener Sentinel-Lymphknoten
 +
|
 +
|1..1
 +
|required
 +
|
 +
 
 +
|-
 +
|7
 +
|bgcolor="ff8888"|act
 +
|@unit
 +
|"1"
 +
|
 +
|1..1
 +
|required
 +
|fix
 +
 
 +
|}
 +
 
 +
 
 +
===Beispiel 1===
 +
 
 +
{{WorkBox|
 +
Abgleich der beiden Beispiele!
 +
}}
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
Zeile 183: Zeile 2.807:
 
</entry>
 
</entry>
 
</syntaxhighlight>
 
</syntaxhighlight>
 +
 +
===Beispiel 2===
 +
 +
Das folgende Beispiel stellt das Maximum der möglichen Angaben dar, wohl wissend, dass dies aus medizinisch-fachlicher Sicht nicht korrekt ist.
 +
 +
<syntaxhighlight lang="XML">
 +
<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>
 +
</syntaxhighlight>
 +
  
 
===verwendete Terminologie===
 
===verwendete Terminologie===

Version vom 10. März 2013, 14:24 Uhr

Dieses Material ist Teil des Leitfadens Arztbrief 2.x.
  • Direkt im Wiki geändert werden sollten Schreibfehler, ergänzende Hinweise.
  • Offene Fragen, die der Diskussionen bedürfen, sollten auf der Diskussionsseite aufgenommen werden.
  • Liste der Seiten dieses Leitfadens: hier, Liste der Seiten, in denen dieses Material verwendet (transkludiert) siehe hier .

Entry: TNM-Klassifikation

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

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 festgestellt (gilt global für die gesamte Klassifikation)
y nach neoadjuvanter Therapie (gilt global für die gesamte Klassifikation)
r Beurteilung eines Rezidivs (gilt global für die gesamte Klassifikation)
T (Primär-)Tumor
N Nodus = Lymphknoten
M Metastasen
S Serumtumormarker
L Lymphgefäßinvasion
V Veneninvasion
Pn Perineuralinvasion


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
SN Sentinel Nodes N
Lok. 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 Immunhistochemie N, M
mol nicht-morphologischer Befund N, M
(kein) Anzahl entfernter und befallener Lymphknoten N


TNM-Klassifikation

Abbildung: Darstellung der TNM-Klassifikation

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)
  |  +- Multiplizität
  +- N-Kategorie (c/p, C, SN)
  |  +- Immunhistochemie
  |  +- nicht-morphologischer Befund
  |  +- Anzahl der untersuchten und positiv bewerteten Knoten
  +- M-Kategorie (c/p, C, Lok.)
  |  +- Immunhistochemie
  |  +- nicht-morphologischer Befund
  +- S (Serumtumormarker)
  +- L (Lymphgefäßinvasion)
  +- V (Veneninvasion)
  +- Pn (Perioneuralscheideninvasion)

Abbildung: Baumdarstellung der TNM-Klassifikation

Anm.: 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.) Codes, über die der Inhalt der Observation-Klasse oder der qualifier bestimmt wird, sind in folgender Tabelle aufgelistet.

Code Codename Klasse / Pfad Darstellung (Observation oder Qualifier)
T T support-Observation Observation/value.@code
M M support-Observation Observation/value.@code
N N support-Observation Observation/value.@code
MP Multiplizität support-Observation(T)-support-Observation Observation/value.@code
CF Certainy Factor support-Observation(T oder N oder M) qualifier.@name
RS Residualtumor support-Observation Observation/value.@code
LI Lymphgefäßinvasion support-Observation Observation/value.@code
VI Veneninvasion support-Observation Observation/value.@code
SG Stadiengruppe support-Observation Observation/value.@code

Tabelle 10: Codes für Tumordiagnosen (OID 1.2.276.0.76.5.334)

Erläuterung

Under construction icon-blue.svg Prüfung und Reduktion der Darstellung, bspw. kodierte Datentypen!


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 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


Beispiel 1

Under construction icon-blue.svg 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

Information icon.svg 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 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 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 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 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

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 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

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)

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