MII IG Kerndatensatz-Modul Onkologie
2027.0.0-ballot.1 -
Germany
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
<Observation xmlns="http://hl7.org/fhir">
<id value="mii-exa-onko-folfox-verlauf-6months"/>
<meta>
<profile
value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-verlauf"/>
</meta>
<language value="de"/>
<text>
<status value="generated"/>
<div xml:lang="de" lang="de"><hr/><p><b>German</b></p><hr/><p class="res-header-id"><b>Generated Narrative: Observation mii-exa-onko-folfox-verlauf-6months</b></p><a name="de-mii-exa-onko-folfox-verlauf-6months"> </a><a name="de-hcmii-exa-onko-folfox-verlauf-6months"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-mii-pr-onko-verlauf.html">MII PR Onkologie Verlauf</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 396432002}">Status of regression of tumor (observable entity)</span></p><p><b>subject</b>: <a href="Patient-mii-exa-onko-folfox-patient.html">Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)</a></p><p><b>focus</b>: <a href="Condition-mii-exa-onko-colorectal-cancer-diagnosis.html">Condition Bösartige Neubildung: Colon sigmoideum</a></p><p><b>effective</b>: 2025-03-15</p><p><b>value</b>: <span title="Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-gesamtbeurteilung V}">Vollremission (complete remission, CR)</span></p><p><b>note</b>: </p><blockquote><div><p>Patient completed 12 cycles of adjuvant FOLFOX4. CT scan and colonoscopy show no evidence of recurrence. CEA level normal (2.1 ng/mL). Patient is disease-free at 6-month follow-up. Plan: Continue surveillance with CEA and imaging every 3-6 months.</p>
</div></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 445200009}">Status of residual neoplasm (observable entity)</span></p><p><b>value</b>: <span title="Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-primaertumor K}">Kein Tumor nachweisbar</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 399656008}">Presence of metastatic neoplasm in regional lymph node (observable entity)</span></p><p><b>value</b>: <span title="Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-lymphknoten K}">kein Lymphknotenbefall nachweisbar</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 399608002}">Status of distant metastasis (observable entity)</span></p><p><b>value</b>: <span title="Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-fernmetastasen K}">Keine Fernmetastasen nachweisbar</span></p></blockquote></div>
</text>
<status value="final"/>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="396432002"/>
<display value="Status of regression of tumor (observable entity)"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/mii-exa-onko-folfox-patient"/>
</subject>
<focus>🔗
<reference value="Condition/mii-exa-onko-colorectal-cancer-diagnosis"/>
</focus>
<effectiveDateTime value="2025-03-15"/>
<valueCodeableConcept>
<coding>
<system
value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-gesamtbeurteilung"/>
<code value="V"/>
<display value="Vollremission (complete remission, CR)"/>
</coding>
</valueCodeableConcept>
<note>
<text
value="Patient completed 12 cycles of adjuvant FOLFOX4. CT scan and colonoscopy show no evidence of recurrence. CEA level normal (2.1 ng/mL). Patient is disease-free at 6-month follow-up. Plan: Continue surveillance with CEA and imaging every 3-6 months."/>
</note>
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="445200009"/>
<display value="Status of residual neoplasm (observable entity)"/>
</coding>
</code>
<valueCodeableConcept>
<coding>
<system
value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-primaertumor"/>
<code value="K"/>
<display value="Kein Tumor nachweisbar"/>
</coding>
</valueCodeableConcept>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="399656008"/>
<display
value="Presence of metastatic neoplasm in regional lymph node (observable entity)"/>
</coding>
</code>
<valueCodeableConcept>
<coding>
<system
value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-lymphknoten"/>
<code value="K"/>
<display value="kein Lymphknotenbefall nachweisbar"/>
</coding>
</valueCodeableConcept>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="399608002"/>
<display value="Status of distant metastasis (observable entity)"/>
</coding>
</code>
<valueCodeableConcept>
<coding>
<system
value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-fernmetastasen"/>
<code value="K"/>
<display value="Keine Fernmetastasen nachweisbar"/>
</coding>
</valueCodeableConcept>
</component>
</Observation>