Dieses Profil beschreibt die Gesamtstatus des Tumorresiduums nach einer (operativen)Therapie in der Onkologie.
Der oBDS-Datensatz sieht abhängig von den durchgeführten Prozeduren entweder eine lokale oder globale Bestimmung des Residualstatus vor. Der OPS-Katalog der Prozeduren, für die ein lokaler Residualstatus erwartet wird, wird von der Plattform §65c bereitgestellt.
Aufgrund des direkten Bezugs wurde die Beurteilung des lokalen Residualstatus nach Abschluss einer Operation als Procedure.outcome in dem Profil Operation abgebildet.
Name | Status | Version | Canonical | Basis |
---|---|---|---|---|
MII_PR_Onko_Residualstatus | draft | 2024.0.0-ballot | https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-residualstatus | http://hl7.org/fhir/StructureDefinition/Observation |
MII_PR_Onko_Residualstatus (Observation) | I | Observation | |
id | Σ | 0..1 | string |
meta | Σ | 0..1 | Meta |
id | 0..1 | string | |
extension | I | 0..* | Extension |
versionId | Σ | 0..1 | id |
lastUpdated | Σ | 0..1 | instant |
source | Σ | 0..1 | uri |
profile | S Σ | 0..* | canonical(StructureDefinition) |
security | Σ | 0..* | CodingBinding |
tag | Σ | 0..* | Coding |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | I | 0..* | Extension |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) |
partOf | S Σ I | 0..1 | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) |
status | Σ ?! | 1..1 | codeBinding |
category | 0..* | CodeableConceptBinding | |
code | S Σ | 1..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | S Σ | 1..* | Coding |
loinc | S Σ | 0..1 | CodingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | Σ | 0..1 | string |
code | S Σ | 1..1 | codePattern |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
snomed | Σ | 0..1 | CodingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 1..1 | uriPattern |
version | Σ | 0..1 | string |
code | Σ | 1..1 | codePattern |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
subject | S Σ I | 1..1 | Reference(Patient) |
focus | S Σ I | 0..* | Reference(MII_PR_Onko_Diagnose) |
encounter | S Σ I | 0..1 | Reference(Encounter) |
effective[x] | Σ | 0..1 | |
effectiveDateTime | dateTime | ||
effectivePeriod | Period | ||
effectiveTiming | Timing | ||
effectiveInstant | instant | ||
issued | Σ | 0..1 | instant |
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) |
value[x] | S Σ I | 1..1 | Binding |
valueCodeableConcept | CodeableConcept | ||
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | Σ | 0..* | Coding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | Σ | 0..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
dataAbsentReason | I | 0..1 | CodeableConceptBinding |
interpretation | 0..* | CodeableConceptBinding | |
note | 0..* | Annotation | |
bodySite | 0..1 | CodeableConcept | |
method | 0..1 | CodeableConcept | |
specimen | I | 0..1 | Reference(Specimen) |
device | I | 0..1 | Reference(Device | DeviceMetric) |
referenceRange | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
low | I | 0..1 | SimpleQuantity |
high | I | 0..1 | SimpleQuantity |
type | 0..1 | CodeableConceptBinding | |
appliesTo | 0..* | CodeableConcept | |
age | I | 0..1 | Range |
text | 0..1 | string | |
hasMember | Σ I | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) |
derivedFrom | Σ I | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) |
component | Σ | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | Σ | 1..1 | CodeableConcept |
value[x] | Σ | 0..1 | |
valueQuantity | Quantity | ||
valueCodeableConcept | CodeableConcept | ||
valueString | string | ||
valueBoolean | boolean | ||
valueInteger | integer | ||
valueRange | Range | ||
valueRatio | Ratio | ||
valueSampledData | SampledData | ||
valueTime | time | ||
valueDateTime | dateTime | ||
valuePeriod | Period | ||
dataAbsentReason | I | 0..1 | CodeableConceptBinding |
interpretation | 0..* | CodeableConceptBinding | |
referenceRange | 0..* | see (referenceRange) |
Umfang eines Residualtumors nach einer Therapie |
Feldname |
---|
Observation.meta.profile |
Observation.partOf |
Observation.code |
Observation.code.coding |
Observation.code.coding:loinc |
Observation.code.coding:loinc.system |
Observation.code.coding:loinc.code |
Observation.subject |
Observation.focus |
Observation.encounter |
Observation.value[x] |
Observation.value[x].coding.system |
Observation.value[x].coding.code |
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="mii-pr-onko-residualstatus" /> <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-residualstatus" /> <version value="2024.0.0-ballot" /> <name value="MII_PR_Onko_Residualstatus" /> <title value="MII PR Onkologie Residualstatus" /> <status value="draft" /> <publisher value="Medizininformatik Initiative" /> <contact> <telecom> <system value="url" /> <value value="https://www.medizininformatik-initiative.de" /> </telecom> </contact> <description value="Umfang eines Residualtumors nach einer Therapie" /> <fhirVersion value="4.0.1" /> <mapping> <identity value="oBDS" /> <name value="Mapping FHIR zu oBDS" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="Observation" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Observation" /> <derivation value="constraint" /> <differential> <element id="Observation"> <path value="Observation" /> <mapping> <identity value="oBDS" /> <map value="10" /> <comment value="Residualstatus" /> </mapping> </element> <element id="Observation.meta.profile"> <path value="Observation.meta.profile" /> <mustSupport value="true" /> </element> <element id="Observation.partOf"> <path value="Observation.partOf" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.code"> <path value="Observation.code" /> <mustSupport value="true" /> </element> <element id="Observation.code.coding"> <path value="Observation.code.coding" /> <slicing> <discriminator> <type value="pattern" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> <mustSupport value="true" /> </element> <element id="Observation.code.coding:loinc"> <path value="Observation.code.coding" /> <sliceName value="loinc" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://loinc.org" /> <code value="84892-9" /> </patternCoding> <mustSupport value="true" /> </element> <element id="Observation.code.coding:loinc.system"> <path value="Observation.code.coding.system" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Observation.code.coding:loinc.code"> <path value="Observation.code.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Observation.code.coding:snomed"> <path value="Observation.code.coding" /> <sliceName value="snomed" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://snomed.info/sct" /> <code value="445200009" /> </patternCoding> </element> <element id="Observation.code.coding:snomed.system"> <path value="Observation.code.coding.system" /> <min value="1" /> </element> <element id="Observation.code.coding:snomed.code"> <path value="Observation.code.coding.code" /> <min value="1" /> </element> <element id="Observation.subject"> <path value="Observation.subject" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> </type> <mustSupport value="true" /> </element> <element id="Observation.focus"> <path value="Observation.focus" /> <type> <code value="Reference" /> <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose" /> </type> <mustSupport value="true" /> </element> <element id="Observation.encounter"> <path value="Observation.encounter" /> <mustSupport value="true" /> </element> <element id="Observation.value[x]"> <path value="Observation.value[x]" /> <min value="1" /> <type> <code value="CodeableConcept" /> </type> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/ValueSet/mii-vs-onko-gesamtbeurteilung-residualstatus" /> </binding> </element> <element id="Observation.value[x].coding.system"> <path value="Observation.value[x].coding.system" /> <min value="1" /> <patternUri value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus" /> <mustSupport value="true" /> </element> <element id="Observation.value[x].coding.code"> <path value="Observation.value[x].coding.code" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="oBDS" /> <map value="10.2" /> <comment value="Gesamtbeurteilung des Residualstatus" /> </mapping> </element> </differential> </StructureDefinition>
{ "resourceType": "StructureDefinition", "id": "mii-pr-onko-residualstatus", "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-residualstatus", "version": "2024.0.0-ballot", "name": "MII_PR_Onko_Residualstatus", "title": "MII PR Onkologie Residualstatus", "status": "draft", "publisher": "Medizininformatik Initiative", "contact": [ { "telecom": [ { "system": "url", "value": "https://www.medizininformatik-initiative.de" } ] } ], "description": "Umfang eines Residualtumors nach einer Therapie", "fhirVersion": "4.0.1", "mapping": [ { "identity": "oBDS", "name": "Mapping FHIR zu oBDS" } ], "kind": "resource", "abstract": false, "type": "Observation", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation", "derivation": "constraint", "differential": { "element": [ { "id": "Observation", "path": "Observation", "mapping": [ { "identity": "oBDS", "map": "10", "comment": "Residualstatus" } ] }, { "id": "Observation.meta.profile", "path": "Observation.meta.profile", "mustSupport": true }, { "id": "Observation.partOf", "path": "Observation.partOf", "max": "1", "mustSupport": true }, { "id": "Observation.code", "path": "Observation.code", "mustSupport": true }, { "id": "Observation.code.coding", "path": "Observation.code.coding", "slicing": { "discriminator": [ { "type": "pattern", "path": "$this" } ], "rules": "open" }, "min": 1, "mustSupport": true }, { "id": "Observation.code.coding:loinc", "path": "Observation.code.coding", "sliceName": "loinc", "min": 0, "max": "1", "patternCoding": { "code": "84892-9", "system": "http://loinc.org" }, "mustSupport": true }, { "id": "Observation.code.coding:loinc.system", "path": "Observation.code.coding.system", "min": 1, "mustSupport": true }, { "id": "Observation.code.coding:loinc.code", "path": "Observation.code.coding.code", "min": 1, "mustSupport": true }, { "id": "Observation.code.coding:snomed", "path": "Observation.code.coding", "sliceName": "snomed", "min": 0, "max": "1", "patternCoding": { "code": "445200009", "system": "http://snomed.info/sct" } }, { "id": "Observation.code.coding:snomed.system", "path": "Observation.code.coding.system", "min": 1 }, { "id": "Observation.code.coding:snomed.code", "path": "Observation.code.coding.code", "min": 1 }, { "id": "Observation.subject", "path": "Observation.subject", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ] } ], "mustSupport": true }, { "id": "Observation.focus", "path": "Observation.focus", "type": [ { "code": "Reference", "targetProfile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose" ] } ], "mustSupport": true }, { "id": "Observation.encounter", "path": "Observation.encounter", "mustSupport": true }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "min": 1, "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/ValueSet/mii-vs-onko-gesamtbeurteilung-residualstatus" } }, { "id": "Observation.value[x].coding.system", "path": "Observation.value[x].coding.system", "min": 1, "patternUri": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus", "mustSupport": true }, { "id": "Observation.value[x].coding.code", "path": "Observation.value[x].coding.code", "min": 1, "mustSupport": true, "mapping": [ { "identity": "oBDS", "map": "10.2", "comment": "Gesamtbeurteilung des Residualstatus" } ] } ] } }
Mapping Datensatz zu FHIR
Datensatz | Erklaerung | FHIR |
---|---|---|
Residualstatus | Residualstatus | |
Beurteilung des lokalen Residualstatus nach Abschluss der Operation | Lokale Beurteilung der Residualklassifikation nach Resektion, bezieht sich auf das, was reseziert wurde, meist Primärtumor, aber z. B. auch Lebermetastasen. | Procedure.outcome |
Gesamtbeurteilung des Residualstatus | Gesamtbeurteilung der Residualklassifikation der Erkrankung einschließlich etwaiger Fernmetastasen. | Observation.valueCodeableConcept.coding.code |
Mapping Einheitlicher onkologischer Basisdatensatz (oBDS) zu FHIR
oBDS | Definition | FHIR |
---|---|---|
10 | Residualstatus | Observation |
10.2 | Gesamtbeurteilung des Residualstatus | Observation.value[x].coding.code |
Suchparameter
Folgende Suchparameter sind für das Modul Onkologie relevant, auch in Kombination:
Der Suchparameter _id
MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?_id=1234
Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "_profile" MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tod
Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "code" MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?code=http://fhir.de/CodeSystem/sct|184305005
Anwendungshinweise: Weitere Informationen zur Suche nach "code" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "subject" MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?subject=Patient/example
Anwendungshinweise: Weitere Informationen zur Suche nach "subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "focus" MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?focus=Condition/example
Anwendungshinweise: Weitere Informationen zur Suche nach "focus" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "encounter" MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?encounter=Encounter/example
Anwendungshinweise: Weitere Informationen zur Suche nach "encounter" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "derived-from" MUSS unterstützt werden:
Beispiele:
GET [base]/Observation?derived-from=Observation/example
Anwendungshinweise: Weitere Informationen zur Suche nach "derived-from" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Beispiele
{ "resourceType": "Observation", "id": "mii-exa-onko-residualstatus-1", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-residualstatus" ] }, "valueCodeableConcept": { "coding": [ { "system": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus", "code": "R0" } ] }, "status": "final", "code": { "coding": [ { "code": "84892-9", "system": "http://loinc.org" } ] }, "subject": { "reference": "Patient/example" }, "effectiveDateTime": "2024-02-08" }