Gleason-Score-Entry (Template)
(Teildokument von Arztbrief 2.x)
Dieses Material ist Teil des Leitfadens Arztbrief 2.x.
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Referenz auf Scores und Assessments |
Entry: Gleason-Score
| Template ID | 1.2.276.0.76.3.1.131.1.10.3.9 | |
| General Description | Gleason-Score (Prostatakarzinom) | |
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TODO: Abgleich mit dem Diagnoseleitfaden ist erforderlich |
TODO: Diagramm ergänzen
| 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 | Gleason-Score | II | 1..1 | required | |||
| 5 | act | @root | "1.2.276.0.76.3.1.131.1.10.3.9" | 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 | "35266-6" | 1..1 | required | fix | |||
| 5 | act | @codeSystem | "2.16.840.1.113883.6.1" | 1..1 | required | fix: LOINC | |||
| 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 Gleason-Score | CD | 1..1 | required | |||
| 5 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 1.2.276.0.76.5.404 | |||
| 5 | act | @codeSystem | "1.2.276.0.76.5.404" | 1..1 | required | fix | |||
| 5 | act | qualifier | CR | 0..1 | optional |
| |||
| 6 | act | name | Gleason 1 (Entdifferenzierungsgrad) | CV | 1..1 | required | |||
| 7 | act | @code | "44641-9" | 1..1 | required | fix | |||
| 7 | act | @codeSystem | "2.16.840.1.113883.6.1" | 1..1 | required | fix: LOINC | |||
| 6 | act | value | Code für den Gleason-Entdifferenzierungsgrad | CV | 1..1 | required | |||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 1.2.276.0.76.5.402 | |||
| 7 | act | @codeSystem | "1.2.276.0.76.5.402" | 1..1 | required | fix | |||
| 5 | act | qualifier | CR | 0..1 | optional |
| |||
| 6 | act | name | Gleason 2 (Wachstumsmuster) | CV | 1..1 | required | |||
| 7 | act | @code | "44642-7" | 1..1 | required | fix | |||
| 7 | act | @codeSystem | "2.16.840.1.113883.6.1" | 1..1 | required | fix: LOINC | |||
| 6 | act | value | Code für das Gleason-Wachstumsmuster | CV | 1..1 | required | |||
| 7 | act | @code | eigentlicher Code | 1..1 | required | Codesystem 1.2.276.0.76.5.403 | |||
| 7 | act | @codeSystem | "1.2.276.0.76.5.403" | 1..1 | required | fix |
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.2.276.0.76.3.1.131.1.10.3.9"/>
<id extension="1234009"
root="1.2.276.0.76.3.1.131.1.4.3.9999.9999.999919"/>
<code code="35266-6"
codeSystem="2.16.840.1.113883.6.1"/>
<text>
Gleason-Score: 4+5=9
</text>
<effectiveTime value="20110326"/>
<value xsi:type="CD" code="9"
codeSystem="1.2.276.0.76.5.404">
<qualifier>
<name code="44641-9"
codeSystem="2.16.840.1.113883.6.1"/>
<value xsi:type="CD" code="4"
codeSystem="1.2.276.0.76.5.402"/>
</qualifier>
<qualifier>
<name code="44642-7"
codeSystem="2.16.840.1.113883.6.1"/>
<value xsi:type="CD" code="5"
codeSystem="1.2.276.0.76.5.403"/>
</qualifier>
</value>
</observation>
