Malignant neoplastic diseases


PARAMETER CASE REPORT FORM RESPONSE OPTIONS
Does the patient suffer from at least one active tumor or cancer disease? Active / Remission / No / Unknown

This profile of a FHIR Condition is derived from the Diagnosis-profile of the Medical Informatics Initiative (MII). The valueset bindings on the Condition.code element have been constrained to solely feature the response options for this particular parameter of the case report form.

To represent the presence, absence or uncertainty of findings, use Condition.verificationStatus or uncertaintyOfPresence on Condition.extension. Note the additional constrain on Condition that checks if either verificationStatus or the extension is present:

unk-1:If verificationStatus is present, uncertaintyOfPresence-Extension SHALL NOT be present.

verificationStatus.exists() != Condition.modifierExtension.where(url = 'https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence').exists()

In addition to the usual approach when capturing presence, absence and uncertainty, the remission of malignant neoplastic diseases is recorded by setting Condition.clinicalStatus to remission. Also check out the extra example below.


Profile - Malignant neoplastic diseases

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/malignant-neoplastic-disease

Snapshot

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
ReferenzPrimaerdiagnoseS I0..1Extension(Reference(Condition))
uncertaintyOfPresenceS ?! I0..1Extension(CodeableConcept)
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
Mehrfachcodierungs-KennzeichenS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
DiagnosesicherheitS I0..1Extension(Coding)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ I1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterS Σ I0..1MII-Reference(Encounter)
id0..1string
dataAbsentReasonI0..1Extension(code)
id0..1string
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
dataAbsentReasonI0..1Extension(code)
value0..1System.DateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation


Extension - Uncertainty of Presence

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence

Snapshot

id0..1string
extensionI0..*Extension
url1..1uriFixed Value
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string


ValueSets

Valuesets are provided with both SNOMED-CT and ICD-10-GM codes.


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/malignant-neoplastic-diseases

ValueSet 'MalignantNeoplasticDiseases'

Version1.0
Published byCharité
StatusActive
ExperimentalFalse

Malignant neoplastic diseases in the context of Covid-19

This value set includes codes from the following code systems:

  • Include codes from SNOMED_CT where concept IsA 363346000


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/malignant-neoplastic-diseases-icd

ValueSet 'MalignantNeoplasticDiseasesICD'

Version1.0.5
Published byCharité
StatusActive
ExperimentalFalse

Malignant neoplastic diseases in the context of Covid-19 from ICD-10-GM

This value set includes codes from the following code systems:

  • Include codes from Icd-10-gm where concept Regex ^C.*
    Include codes from Icd-10-gm where child Exists false


Examples

Malignant neoplastic disease active
Example condition that is confirmed present

{
    "resourceType": "Condition",
    "id": "540c7ce3-752c-4565-821b-fecce54b77d6",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/malignant-neoplastic-disease"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active",
                "display": "Active"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed",
                "display": "Confirmed"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410605003",
                "display": "Confirmed present (qualifier value)"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "394593009",
                    "display": "Medical oncology (qualifier value)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "363346000",
                "display": "Malignant neoplastic disease"
            }
        ]
    },
    "subject": {
        "reference": "Patient/004e1d34-ee10-46d0-9a1c-2444e3295c4c"
    },
    "recordedDate": "2020-10-06"
}


Malignant neoplastic disease in remission
Example condition that is confirmed absent

{
    "resourceType": "Condition",
    "id": "9cf51de2-6bde-4921-a41a-677869f4c74a",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/malignant-neoplastic-disease"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "remission",
                "display": "Remission"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed",
                "display": "Confirmed"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410605003",
                "display": "Confirmed present (qualifier value)"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "394593009",
                    "display": "Medical oncology (qualifier value)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "363346000",
                "display": "Malignant neoplastic disease"
            }
        ]
    },
    "subject": {
        "reference": "Patient/004e1d34-ee10-46d0-9a1c-2444e3295c4c"
    },
    "recordedDate": "2020-10-06"
}


Malignant neoplastic disease absent
Example condition that is confirmed absent

{
    "resourceType": "Condition",
    "id": "3ac50369-07cf-41e0-b28a-1a1ca4698779",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/malignant-neoplastic-disease"
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "refuted",
                "display": "Refuted"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410594000",
                "display": "Definitely NOT present (qualifier value)"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "394593009",
                    "display": "Medical oncology (qualifier value)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "363346000",
                "display": "Malignant neoplastic disease"
            }
        ]
    },
    "subject": {
        "reference": "Patient/004e1d34-ee10-46d0-9a1c-2444e3295c4c"
    },
    "recordedDate": "2020-10-06"
}


Malignant neoplastic disease unknown
Example condition where the presence is unknown

{
    "resourceType": "Condition",
    "id": "31b5aa8f-a59a-41c8-97a4-a1d48867549c",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/malignant-neoplastic-disease"
        ]
    },
    "modifierExtension":  [
        {
            "url": "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://snomed.info/sct",
                        "code": "261665006",
                        "display": "Unknown (qualifier value)"
                    }
                ],
                "text": "Presence of condition is unknown."
            }
        }
    ],
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "394593009",
                    "display": "Medical oncology (qualifier value)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "363346000",
                "display": "Malignant neoplastic disease"
            }
        ]
    },
    "subject": {
        "reference": "Patient/004e1d34-ee10-46d0-9a1c-2444e3295c4c"
    },
    "recordedDate": "2020-10-06"
}