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 Melanom Bundle

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{
  "resourceType" : "Bundle",
  "id" : "mii-exa-onko-melanom-bundle",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/StructureDefinition/Bundle"
    ]
  },
  "language" : "de",
  "identifier" : {
    "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko",
    "value" : "melanom-example-bundle-2024-001"
  },
  "type" : "transaction",
  "timestamp" : "2024-03-25T10:00:00+01:00",
  "entry" : [
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Patient/mii-exa-onko-melanom-bundle-patient",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "mii-exa-onko-melanom-bundle-patient",
        "language" : "de",
        "text" : {
          "status" : "generated"
        },
        "name" : [
          {
            "family" : "Melanom",
            "given" : [
              "Maria"
            ]
          }
        ]
      },
      "request" : {
        "method" : "POST",
        "url" : "Patient"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-melanom-diagnose",
      "resource" : {
        "resourceType" : "Condition",
        "id" : "mii-exa-onko-melanom-diagnose",
        "meta" : {
          "profile" : [
            🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose-primaertumor|2027.0.0-ballot.1"
          ]
        },
        "language" : "de",
        "text" : {
          "status" : "extensions"
        },
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/condition-assertedDate",
            "valueDateTime" : "2024-01-02"
          }
        ],
        "clinicalStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
              "code" : "active"
            }
          ]
        },
        "verificationStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status",
              "code" : "confirmed"
            },
            {
              "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-primaertumor-diagnosesicherung",
              "code" : "7.1",
              "display" : "histologische Untersuchung eines Primärtumors"
            }
          ]
        },
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "55342001",
                "display" : "Neoplastic disease"
              }
            ]
          }
        ],
        "code" : {
          "coding" : [
            {
              "system" : "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
              "version" : "2024",
              "code" : "C43.9",
              "display" : "Bösartiges Melanom der Haut, nicht näher bezeichnet"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        },
        "encounter" : {
          🔗 "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter"
        },
        "recordedDate" : "2024-01-02"
      },
      "request" : {
        "method" : "POST",
        "url" : "Condition"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-melanom-bundle-encounter",
      "resource" : {
        "resourceType" : "Encounter",
        "id" : "mii-exa-onko-melanom-bundle-encounter",
        "language" : "de",
        "text" : {
          "status" : "generated"
        },
        "status" : "finished",
        "class" : {
          "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
          "code" : "IMP",
          "display" : "inpatient encounter"
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        }
      },
      "request" : {
        "method" : "POST",
        "url" : "Encounter"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-sicherheitsabstand",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "mii-exa-onko-melanom-sicherheitsabstand",
        "meta" : {
          "profile" : [
            🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-sicherheitsabstand"
          ]
        },
        "language" : "de",
        "text" : {
          "status" : "generated"
        },
        "status" : "final",
        "code" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "396511007",
              "display" : "Distance of in situ melanoma from closest lateral surgical margin in excised specimen of skin (observable entity)"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        },
        "focus" : [
          {
            🔗 "reference" : "Condition/mii-exa-onko-melanom-diagnose"
          }
        ],
        "encounter" : {
          🔗 "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter"
        },
        "effectiveDateTime" : "2024-03-25T10:00:00+01:00",
        "valueQuantity" : {
          "value" : 5,
          "unit" : "mm",
          "system" : "http://unitsofmeasure.org",
          "code" : "mm"
        }
      },
      "request" : {
        "method" : "POST",
        "url" : "Observation"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-breslow-tiefe",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "mii-exa-onko-melanom-breslow-tiefe",
        "meta" : {
          "profile" : [
            🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-breslow-tiefe"
          ]
        },
        "language" : "de",
        "text" : {
          "status" : "generated"
        },
        "status" : "final",
        "code" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "106243009",
              "display" : "Breslow depth staging for melanoma of skin (observable entity)"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        },
        "focus" : [
          {
            🔗 "reference" : "Condition/mii-exa-onko-melanom-diagnose"
          }
        ],
        "encounter" : {
          🔗 "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter"
        },
        "effectiveDateTime" : "2024-03-20T14:30:00+01:00",
        "valueQuantity" : {
          "value" : 2.1,
          "unit" : "mm",
          "system" : "http://unitsofmeasure.org",
          "code" : "mm"
        },
        "method" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "117617002",
              "display" : "Immunohistochemistry procedure"
            }
          ]
        }
      },
      "request" : {
        "method" : "POST",
        "url" : "Observation"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-ulzeration",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "mii-exa-onko-melanom-ulzeration",
        "meta" : {
          "profile" : [
            🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-ulzeration"
          ]
        },
        "language" : "de",
        "text" : {
          "status" : "generated"
        },
        "status" : "final",
        "code" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "6270001000004106",
              "display" : "Presence of ulcer in primary malignant melanoma of skin (observable entity)"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        },
        "focus" : [
          {
            🔗 "reference" : "Condition/mii-exa-onko-melanom-diagnose"
          }
        ],
        "encounter" : {
          🔗 "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter"
        },
        "effectiveDateTime" : "2024-03-20T14:30:00+01:00",
        "valueCodeableConcept" : {
          "coding" : [
            {
              "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-melanom-ulzeration",
              "code" : "J",
              "display" : "Ja"
            }
          ]
        },
        "method" : {
          "coding" : [
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              "system" : "http://snomed.info/sct",
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            }
          ]
        }
      },
      "request" : {
        "method" : "POST",
        "url" : "Observation"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-ldh",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "mii-exa-onko-melanom-ldh",
        "meta" : {
          "profile" : [
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          ]
        },
        "language" : "de",
        "text" : {
          "status" : "generated"
        },
        "status" : "final",
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
                "code" : "laboratory",
                "display" : "Laboratory"
              }
            ]
          }
        ],
        "code" : {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "14804-9",
              "display" : "Lactate dehydrogenase [Enzymatic activity/volume] in Serum or Plasma by Lactate to pyruvate reaction"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        },
        "focus" : [
          {
            🔗 "reference" : "Condition/mii-exa-onko-melanom-diagnose"
          }
        ],
        "encounter" : {
          🔗 "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter"
        },
        "effectiveDateTime" : "2024-03-18T08:30:00+01:00",
        "valueQuantity" : {
          "value" : 280,
          "unit" : "U/L",
          "system" : "http://unitsofmeasure.org",
          "code" : "U/L"
        },
        "interpretation" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
                "code" : "H",
                "display" : "High"
              }
            ]
          }
        ],
        "referenceRange" : [
          {
            "low" : {
              "value" : 135,
              "unit" : "U/L",
              "system" : "http://unitsofmeasure.org",
              "code" : "U/L"
            },
            "high" : {
              "value" : 250,
              "unit" : "U/L",
              "system" : "http://unitsofmeasure.org",
              "code" : "U/L"
            },
            "text" : "135-250 U/L"
          }
        ]
      },
      "request" : {
        "method" : "POST",
        "url" : "Observation"
      }
    },
    {
      "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-melanom-exzision-oberarm",
      "resource" : {
        "resourceType" : "Procedure",
        "id" : "mii-exa-onko-melanom-exzision-oberarm",
        "meta" : {
          "profile" : [
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          ]
        },
        "language" : "de",
        "text" : {
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        },
        "extension" : [
          {
            "url" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention",
            "valueCodeableConcept" : {
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                  "code" : "K",
                  "display" : "kurativ"
                }
              ]
            }
          }
        ],
        "status" : "completed",
        "category" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "387713003",
              "display" : "Surgical procedure"
            }
          ]
        },
        "code" : {
          "coding" : [
            {
              "system" : "http://fhir.de/CodeSystem/bfarm/ops",
              "version" : "2024",
              "code" : "5-894.06",
              "display" : "Lokale Exzision von erkranktem Gewebe an Haut und Unterhaut: Ohne primären Wundverschluss: Schulter und Axilla"
            },
            {
              "system" : "http://snomed.info/sct",
              "code" : "177281002",
              "display" : "Excision of melanoma (procedure)"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/mii-exa-onko-melanom-bundle-patient"
        },
        "performedDateTime" : "2024-03-20",
        "reasonReference" : [
          {
            🔗 "reference" : "Condition/mii-exa-onko-melanom-diagnose"
          }
        ],
        "bodySite" : [
          {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "368208006",
                "display" : "Left upper arm structure"
              }
            ]
          }
        ],
        "outcome" : {
          "coding" : [
            {
              "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus",
              "code" : "R0",
              "display" : "Kein Residualtumor"
            }
          ]
        }
      },
      "request" : {
        "method" : "POST",
        "url" : "Procedure"
      }
    }
  ]
}