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. For a full list of available versions, see the Directory of published versions
Language: de
Bundle mii-exa-onko-folfox-workflow-bundle of type collection
Entry 1 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Patient/mii-exa-onko-folfox-patient
Resso}:
Language: de
Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)
Entry 2 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-folfox-encounter-diagnosis
Resso}:
Language: de
status: Finished
class: ActCode: AMB (ambulatory)
Entry 3 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-folfox-encounter-surgery
Resso}:
Language: de
status: Finished
class: ActCode: IMP (inpatient encounter)
Entry 4 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-folfox-encounter-chemo
Resso}:
Language: de
status: Finished
class: ActCode: AMB (ambulatory)
Entry 5 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-colorectal-cancer-diagnosis
Resso}:
Language: de
Condition Asserted Date: 2024-01-15
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis, Neoplastic disease
code: Bösartige Neubildung: Colon sigmoideum
encounter: Encounter: status = finished; class = ambulatory (ActCode#AMB)
onset: 2024-01-15
recordedDate: 2024-01-15
note:
Adenokarzinom des Colon sigmoideum, Stadium III (T3N1M0)
Entry 6 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-colorectal-tnm-t
Resso}:
Language: de
Profile: MII PR Onkologie TNM T-Kategorie version: 2027.0.0-ballot.1
status: Final
code: pT category (observable entity)
focus: Condition Bösartige Neubildung: Colon sigmoideum
effective: 2024-02-20
value: T3
method: 8. Auflage
Entry 7 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-colorectal-tnm-n
Resso}:
Language: de
Profile: MII PR Onkologie TNM N-Kategorie version: 2027.0.0-ballot.1
status: Final
code: pN category (observable entity)
focus: Condition Bösartige Neubildung: Colon sigmoideum
effective: 2024-02-20
value: N1
method: 8. Auflage
Entry 8 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-colorectal-tnm-m
Resso}:
Language: de
Profile: MII PR Onkologie TNM M-Kategorie version: 2027.0.0-ballot.1
status: Final
code: cM category (observable entity)
focus: Condition Bösartige Neubildung: Colon sigmoideum
effective: 2024-02-20
value: M0
method: 8. Auflage
Entry 9 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-colorectal-tnm
Resso}:
Language: de
Profile: MII PR Onkologie TNM-Klassifikation
status: Final
code: Pathologic TNM stage grouping
focus: Condition Bösartige Neubildung: Colon sigmoideum
effective: 2024-02-20
value: Stadium IIIB
method: 8. Auflage
hasMember:
Entry 10 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CarePlan/mii-exa-onko-tumorkonferenz-folfox
Resso}:
Language: de
Profile: MII PR Onkologie Tumorkonferenz version: 2027.0.0-ballot.1
identifier: Tumorkonferenz_FOLFOX_001
status: Active
intent: Plan
category: prätherapeutische Tumorkonferenz (Festlegung der Therapiestrategie)
created: 2024-03-10
addresses: Condition Bösartige Neubildung: Colon sigmoideum
Activities
Progress Reference Tumor board recommends FOLFOX chemotherapy protocol for stage III colon cancer, adjuvant setting
RequestGroup Chemotherapie
Entry 11 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/RequestGroup/mii-exa-onko-folfox-requestgroup
Resso}:
Language: de
Profile: MII PR Onkologie Therapieempfehlung Kombinationstherapie version: 2027.0.0-ballot.1
status: Active
intent: Proposal
code: Chemotherapie
authoredOn: 2024-03-10
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
action
title: FOLFOX4 Protocol
description: FOLFOX4 chemotherapy protocol: Fluorouracil + Folinsäure + Oxaliplatin
code: FOLFOX4
Actions
Title Description Resource Fluorouracil (5-FU) 5-Fluorouracil - pyrimidine analog, antineoplastic MedicationRequest: status = active; intent = proposal; medication[x] = Fluorouracil; authoredOn = 2024-03-10 Folinsäure (Leucovorin) Folinic acid - enhances 5-FU efficacy MedicationRequest: status = active; intent = proposal; medication[x] = Calciumfolinat; authoredOn = 2024-03-10 Oxaliplatin Platinum-based chemotherapy agent MedicationRequest: status = active; intent = proposal; medication[x] = Oxaliplatin; authoredOn = 2024-03-10
Entry 12 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/MedicationRequest/mii-exa-onko-folfox-5fu-request
Resso}:
Language: de
Profile: MII PR Onkologie Therapieempfehlung Medikation version: 2027.0.0-ballot.1
status: Active
intent: Proposal
medication: 5-Fluorouracil (5-FU)
authoredOn: 2024-03-10
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
Entry 13 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/MedicationRequest/mii-exa-onko-folfox-leucovorin-request
Resso}:
Language: de
Profile: MII PR Onkologie Therapieempfehlung Medikation version: 2027.0.0-ballot.1
status: Active
intent: Proposal
medication: Leucovorin (Folinsäure)
authoredOn: 2024-03-10
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
Entry 14 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/MedicationRequest/mii-exa-onko-folfox-oxaliplatin-request
Resso}:
Language: de
Profile: MII PR Onkologie Therapieempfehlung Medikation version: 2027.0.0-ballot.1
status: Active
intent: Proposal
medication: Oxaliplatin
authoredOn: 2024-03-10
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
Entry 15 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-sigmoid-resection
Resso}:
Language: de
Profile: MII PR Onkologie Operation
MII EX Onko Operation Intention: Kurativ
status: Completed
category: Surgical procedure
code: Laparoskopische Sigmaresektion mit TME und Lymphknotendissektion
encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)
performed: 2024-02-15
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
outcome: Kein Residualtumor
note:
Laparoscopic sigmoid resection with TME and lymphadenectomy. No intraoperative complications. Tumor completely resected with clear margins (R0). 18 lymph nodes removed, 3 positive. Surgery performed in 3 components: resection, anastomosis, and lymph node dissection.
Entry 16 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-sigmoid-resection-part1
Resso}:
Language: de
Profile: MII PR Onkologie Operation
MII EX Onko Operation Intention: Kurativ
partOf: Procedure Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion
status: Completed
category: Surgical procedure
code: Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion
encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)
performed: 2024-02-15
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
note:
Sigmoid colon resected including tumor. End-to-end anastomosis created.
Entry 17 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-sigmoid-resection-part2
Resso}:
Language: de
Profile: MII PR Onkologie Operation
MII EX Onko Operation Intention: Kurativ
partOf: Procedure Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion
status: Completed
category: Surgical procedure
code: Radikale (systematische) Lymphadenektomie im Rahmen einer anderen Operation: Axillär
encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)
performed: 2024-02-15
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
note:
Regional lymph node dissection performed. 18 lymph nodes removed from mesenteric and para-aortic regions.
Entry 18 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-sigmoid-resection-part3
Resso}:
Language: de
Profile: MII PR Onkologie Operation
MII EX Onko Operation Intention: Kurativ
partOf: Procedure Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion
status: Completed
category: Surgical procedure
code: Minimalinvasive Technik: Sonstige
encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)
performed: 2024-02-15
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
note:
Four laparoscopic ports placed for minimally invasive approach.
Entry 19 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-folfox-procedure
Resso}:
Language: de
MII EX Onko Systemische Therapie Intention: Kurativ
MII EX Onko Systemische Therapie Stellung zur OP: Adjuvant
status: Completed
category: Therapeutic procedure
code: Nicht komplexe Chemotherapie
encounter: Encounter: status = finished; class = ambulatory (ActCode#AMB)
performed: 2024-03-20 --> 2024-09-15
reasonReference: Condition Bösartige Neubildung: Colon sigmoideum
outcome: Reguläres Ende
note:
Patient received 12 cycles of adjuvant FOLFOX4 chemotherapy for stage III colon cancer. Treatment completed without major complications.
usedCode: FOLFOX4
Entry 20 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/MedicationStatement/mii-exa-onko-folfox-5fu-statement
Resso}:
Language: de
partOf: Procedure Nicht komplexe Chemotherapie
status: Completed
medication: 5-Fluorouracil (5-FU)
effective: 2024-03-20 --> 2024-09-15
note:
FOLFOX4
Entry 21 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/MedicationStatement/mii-exa-onko-folfox-leucovorin-statement
Resso}:
Language: de
partOf: Procedure Nicht komplexe Chemotherapie
status: Completed
medication: Leucovorin (Folinsäure)
effective: 2024-03-20 --> 2024-09-15
note:
FOLFOX4
Entry 22 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/MedicationStatement/mii-exa-onko-folfox-oxaliplatin-statement
Resso}:
Language: de
partOf: Procedure Nicht komplexe Chemotherapie
status: Completed
medication: Oxaliplatin
effective: 2024-03-20 --> 2024-09-15
note:
FOLFOX4
Entry 23 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-folfox-verlauf-6months
Resso}:
Language: de
Profile: MII PR Onkologie Verlauf
status: Final
code: Status of regression of tumor (observable entity)
focus: Condition Bösartige Neubildung: Colon sigmoideum
effective: 2025-03-15
value: Vollremission (complete remission, CR)
note:
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.
component
code: Status of residual neoplasm (observable entity)
value: Kein Tumor nachweisbar
component
code: Presence of metastatic neoplasm in regional lymph node (observable entity)
value: kein Lymphknotenbefall nachweisbar
component
code: Status of distant metastasis (observable entity)
value: Keine Fernmetastasen nachweisbar