MII IG Kerndatensatz-Modul Onkologie
2027.0.0-ballot.1 - Germany

This page is part of the MII IG Kerndatensatz-Modul Onkologie (v2027.0.0-ballot.1: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: MII EXA Onko Mamma Bundle

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="mii-exa-onko-mamma-example-bundle-1"/>
  <meta>
    <profile value="http://hl7.org/fhir/StructureDefinition/Bundle"/>
  </meta>
  <language value="de"/>
  <identifier>
    <system
            value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko"/>
    <value value="mamma-example-bundle-2024-001"/>
  </identifier>
  <type value="transaction"/>
  <timestamp value="2024-03-25T10:00:00+01:00"/>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Patient/mii-exa-onko-mamma-bundle-patient"/>
    <resource>
      <Patient>
        <id value="mii-exa-onko-mamma-bundle-patient"/>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <name>
          <family value="MammaCa"/>
          <given value="Martha"/>
        </name>
      </Patient>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Patient"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-mamma-diagnose"/>
    <resource>
      <Condition>
        <id value="mii-exa-onko-mamma-diagnose"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose-primaertumor"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="extensions"/>
        </text>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/condition-assertedDate">
          <valueDateTime value="2020-03-07"/>
        </extension>
        <clinicalStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
            <code value="active"/>
          </coding>
        </clinicalStatus>
        <verificationStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
            <code value="confirmed"/>
          </coding>
        </verificationStatus>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="55342001"/>
            <display value="Neoplastic disease"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://fhir.de/CodeSystem/bfarm/icd-10-gm"/>
            <version value="2024"/>
            <code value="C50.3"/>
            <display
                     value="Bösartige Neubildung: Unterer innerer Quadrant der Brustdrüse"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
        <recordedDate value="2024-01-02"/>
      </Condition>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Condition"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-mamma-bundle-encounter"/>
    <resource>
      <Encounter>
        <id value="mii-exa-onko-mamma-bundle-encounter"/>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="finished"/>
        <class>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          <code value="IMP"/>
          <display value="inpatient encounter"/>
        </class>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
      </Encounter>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Encounter"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-mamma-menopause-status-1"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-mamma-menopause-status-1"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-mamma-menopause-status|2027.0.0-ballot.1"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="161712005"/>
            <display value="Menopause, function (observable entity)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-mamma-diagnose"/>
        </focus>
        <valueCodeableConcept>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="22636003"/>
            <display value="Premenopausal state (finding)"/>
          </coding>
        </valueCodeableConcept>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-mamma-rezeptorstatus-estrogen-1"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-mamma-rezeptorstatus-estrogen-1"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-mamma-rezeptorstatus-estrogen|2027.0.0-ballot.1"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="40556-3"/>
            <display
                     value="Estrogen receptor Ag [Presence] in Tissue by Immune stain"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-mamma-diagnose"/>
        </focus>
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="LA6576-8"/>
            <display value="Positive"/>
          </coding>
        </valueCodeableConcept>
        <component>
          <code>
            <coding>
              <system value="http://snomed.info/sct"/>
              <code value="1234804006"/>
              <display
                       value="Percent of cells with estrogen receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)"/>
            </coding>
          </code>
          <valueQuantity>
            <value value="5"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
          </valueQuantity>
        </component>
        <component>
          <code>
            <coding>
              <system value="http://snomed.info/sct"/>
              <code value="1236874005"/>
              <display
                       value="Intensity of stain of estrogen receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)"/>
            </coding>
          </code>
          <valueCodeableConcept>
            <coding>
              <system value="http://loinc.org"/>
              <code value="LA13034-6"/>
              <display value="Weak"/>
            </coding>
          </valueCodeableConcept>
        </component>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-mamma-rezeptorstatus-progesteron-1"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-mamma-rezeptorstatus-progesteron-1"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-mamma-rezeptorstatus-progesteron|2027.0.0-ballot.1"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="85339-0"/>
            <display
                     value="Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-mamma-diagnose"/>
        </focus>
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="LA6576-8"/>
            <display value="Positive"/>
          </coding>
        </valueCodeableConcept>
        <component>
          <code>
            <coding>
              <system value="http://snomed.info/sct"/>
              <code value="1234803000"/>
              <display
                       value="Percent of cells with progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry"/>
            </coding>
          </code>
          <valueQuantity>
            <value value="25"/>
            <unit value="%"/>
            <system value="http://unitsofmeasure.org"/>
          </valueQuantity>
        </component>
        <component>
          <code>
            <coding>
              <system value="http://snomed.info/sct"/>
              <code value="1237278006"/>
              <display
                       value="Intensity of stain of progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)"/>
            </coding>
          </code>
          <valueCodeableConcept>
            <coding>
              <system value="http://loinc.org"/>
              <code value="LA13034-6"/>
              <display value="Weak"/>
            </coding>
          </valueCodeableConcept>
        </component>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-mamma-tumorgroesse-1"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-mamma-tumorgroesse-1"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorgroesse|2027.0.0-ballot.1"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="21889-1"/>
            <display value="Size Tumor"/>
          </coding>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="371479009"/>
            <display
                     value="Tumor size, largest dimension (observable entity)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-mamma-diagnose"/>
        </focus>
        <effectiveDateTime value="2024-01-02T10:00:00Z"/>
        <valueQuantity>
          <value value="25"/>
          <unit value="mm"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mm"/>
        </valueQuantity>
        <bodySite>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="110494001"/>
            <display
                     value="Structure of upper inner quadrant of right breast (body structure)"/>
          </coding>
        </bodySite>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-mamma-praeoperative-markierung-1"/>
    <resource>
      <Procedure>
        <id value="mii-exa-onko-mamma-praeoperative-markierung-1"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-mamma-praeoperative-markierung|2027.0.0-ballot.1"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="completed"/>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="103693007"/>
            <display value="Diagnostic procedure (procedure)"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="433222002"/>
            <display
                     value="Insertion of guide wire into breast using ultrasound guidance (procedure)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-mamma-bundle-patient"/>
        </subject>
        <performedDateTime value="2024-01-15T09:00:00+01:00"/>
        <reasonReference>🔗 
          <reference value="Condition/mii-exa-onko-mamma-diagnose"/>
        </reasonReference>
      </Procedure>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Procedure"/>
    </request>
  </entry>
</Bundle>