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

: Melanom Exzision Rücken Beispiel

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<Procedure xmlns="http://hl7.org/fhir">
  <id value="mii-exa-onko-melanom-exzision-ruecken"/>
  <meta>
    <profile
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-exzision|2027.0.0-ballot.1"/>
  </meta>
  <language value="de"/>
  <text>
    <status value="extensions"/>
    <div xml:lang="de" lang="de"><hr/><p><b>German</b></p><hr/><p class="res-header-id"><b>Generated Narrative: Procedure mii-exa-onko-melanom-exzision-ruecken</b></p><a name="de-mii-exa-onko-melanom-exzision-ruecken"> </a><a name="de-hcmii-exa-onko-melanom-exzision-ruecken"> </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-melanom-exzision.html">MII PR Onko Melanom Exzision</a> version: 2027.0.0-ballot.1</p></div><p><b>MII EX Onko Operation Intention</b>: <span title="Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention K}">kurativ</span></p><p><b>status</b>: Completed</p><p><b>category</b>: <span title="Codes:{http://snomed.info/sct 387713003}">Surgical procedure</span></p><p><b>code</b>: <span title="Codes:{http://fhir.de/CodeSystem/bfarm/ops 5-894.0a}, {http://snomed.info/sct 177281002}">Lokale Exzision von erkranktem Gewebe an Haut und Unterhaut: Ohne primären Wundverschluss: Brustwand und Rücken</span></p><p><b>subject</b>: <a href="Patient-mii-exa-onko-melanom-bundle-patient.html">Maria Melanom  (no stated gender), DoB Unknown</a></p><p><b>performed</b>: 2024-04-05</p><p><b>reasonReference</b>: <a href="Condition-mii-exa-onko-melanom-diagnose.html">Condition Bösartiges Melanom der Haut, nicht näher bezeichnet</a></p><p><b>bodySite</b>: <span title="Codes:{http://snomed.info/sct 304036007}">Structure of posterior region of neck</span></p><p><b>outcome</b>: <span title="Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus R0}">Kein Residualtumor</span></p><p><b>note</b>: </p><blockquote><div><p>Nachexzision mit 2cm Sicherheitsabstand</p>
</div></blockquote></div>
  </text>
  <extension
             url="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention">
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention"/>
        <code value="K"/>
        <display value="kurativ"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <status value="completed"/>
  <category>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="387713003"/>
      <display value="Surgical procedure"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://fhir.de/CodeSystem/bfarm/ops"/>
      <version value="2024"/>
      <code value="5-894.0a"/>
      <display
               value="Lokale Exzision von erkranktem Gewebe an Haut und Unterhaut: Ohne primären Wundverschluss: Brustwand und Rücken"/>
    </coding>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="177281002"/>
      <display value="Excision of melanoma (procedure)"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/mii-exa-onko-melanom-bundle-patient"/>
  </subject>
  <performedDateTime value="2024-04-05"/>
  <reasonReference>🔗 
    <reference value="Condition/mii-exa-onko-melanom-diagnose"/>
  </reasonReference>
  <bodySite>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="304036007"/>
      <display value="Structure of posterior region of neck"/>
    </coding>
  </bodySite>
  <outcome>
    <coding>
      <system
              value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus"/>
      <code value="R0"/>
      <display value="Kein Residualtumor"/>
    </coding>
  </outcome>
  <note>
    <text value="Nachexzision mit 2cm Sicherheitsabstand"/>
  </note>
</Procedure>