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
{
"resourceType" : "Bundle",
"id" : "mii-exa-onko-krk-bundle",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/Bundle"
]
},
"language" : "de",
"identifier" : {
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko",
"value" : "krk-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-krk-bundle-patient",
"resource" : {
"resourceType" : "Patient",
"id" : "mii-exa-onko-krk-bundle-patient",
"language" : "de",
"text" : {
"status" : "generated"
},
"name" : [
{
"family" : "KolorektalCa",
"given" : [
"Klaus"
]
}
]
},
"request" : {
"method" : "POST",
"url" : "Patient"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-krk-diagnose",
"resource" : {
"resourceType" : "Condition",
"id" : "mii-exa-onko-krk-diagnose",
"meta" : {
"profile" : [
🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose-primaertumor"
]
},
"language" : "de",
"text" : {
"status" : "extensions"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/condition-assertedDate",
"valueDateTime" : "2020-03-07"
}
],
"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"
}
]
},
"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" : "C18",
"display" : "Bösartige Neubildung des Kolons"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"recordedDate" : "2024-01-02"
},
"request" : {
"method" : "POST",
"url" : "Condition"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-krk-bundle-encounter",
"resource" : {
"resourceType" : "Encounter",
"id" : "mii-exa-onko-krk-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-krk-bundle-patient"
}
},
"request" : {
"method" : "POST",
"url" : "Encounter"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-abstand-tumor-anokutanlinie",
"resource" : {
"resourceType" : "Observation",
"id" : "mii-exa-onko-krk-abstand-tumor-anokutanlinie",
"meta" : {
"profile" : [
🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-abstand-anokutan"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "33748-5",
"display" : "Distance from anal verge"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"focus" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"effectiveDateTime" : "2024-03-10T14:30:00+01:00",
"valueQuantity" : {
"value" : 8.5,
"unit" : "cm",
"system" : "http://unitsofmeasure.org",
"code" : "cm"
}
},
"request" : {
"method" : "POST",
"url" : "Observation"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-abstand-circumferelle-resektionsebene",
"resource" : {
"resourceType" : "Observation",
"id" : "mii-exa-onko-krk-abstand-circumferelle-resektionsebene",
"meta" : {
"profile" : [
🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-abstand-circumferelle-resektionsebene"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "81176-0",
"display" : "Distance of tumor from circumferential resection margin [Length] in Specimen by Macroscopy"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"focus" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"effectiveDateTime" : "2024-03-20T10:15:00+01:00",
"valueQuantity" : {
"value" : 2.5,
"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-krk-abstand-resektionsrand-aboral",
"resource" : {
"resourceType" : "Observation",
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"meta" : {
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🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-abstand-aboral"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "81175-2",
"display" : "Distance of tumor from closest margin [Length] in Specimen by Macroscopy"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"focus" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"effectiveDateTime" : "2024-03-20T10:15:00+01:00",
"valueQuantity" : {
"value" : 15,
"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-krk-abstand-mesorektale-fascie",
"resource" : {
"resourceType" : "Observation",
"id" : "mii-exa-onko-krk-abstand-mesorektale-fascie",
"meta" : {
"profile" : [
🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-mrt-mesorektale-faszie"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "https://radelement.org",
"code" : "RDE96",
"display" : "Distance to MRF"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"focus" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"effectiveDateTime" : "2024-03-12T16:00:00+01:00",
"valueQuantity" : {
"value" : 3.2,
"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-krk-anastomoseninsuffizienz",
"resource" : {
"resourceType" : "Observation",
"id" : "mii-exa-onko-krk-anastomoseninsuffizienz",
"meta" : {
"profile" : [
🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-anastomoseninsuffizienz"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "236091002",
"display" : "Large intestine anastomotic leak (disorder)"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"focus" : [
{
🔗 "reference" : "Procedure/mii-exa-onko-krk-operation"
}
],
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"effectiveDateTime" : "2024-03-25T08:00:00+01:00",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-krk-anastomoseninsuffizienz",
"code" : "B",
"display" : "Anastomoseninsuffizienz Grad B"
}
]
}
},
"request" : {
"method" : "POST",
"url" : "Observation"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-asa-klassifikation",
"resource" : {
"resourceType" : "Observation",
"id" : "mii-exa-onko-asa-klassifikation",
"meta" : {
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🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-asa-klassifikation"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "97816-3",
"display" : "American society of anesthesiologists morbidity state"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"focus" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"effectiveDateTime" : "2024-03-15T08:30:00+01:00",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-asa-obds",
"code" : "2",
"display" : "ASA II"
}
]
}
},
"request" : {
"method" : "POST",
"url" : "Observation"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-krk-stoma-markierung",
"resource" : {
"resourceType" : "Procedure",
"id" : "mii-exa-onko-krk-stoma-markierung",
"meta" : {
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🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-stoma-markierung"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"status" : "completed",
"statusReason" : {
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"code" : "262008008",
"display" : "Not performed (qualifier value)"
}
]
},
"category" : {
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{
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"code" : "387713003",
"display" : "Surgical procedure"
}
]
},
"code" : {
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{
"system" : "http://snomed.info/sct",
"code" : "225134005",
"display" : "Marking position of planned stoma site (procedure)"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"performedDateTime" : "2024-03-15T09:30:00+01:00",
"reasonReference" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"note" : [
{
"text" : "Präoperative Markierung der geplanten Stoma-Position im rechten Hemiabdomen nach Rücksprache mit dem Patienten"
}
]
},
"request" : {
"method" : "POST",
"url" : "Procedure"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-krk-operation",
"resource" : {
"resourceType" : "Procedure",
"id" : "mii-exa-onko-krk-operation",
"meta" : {
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🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-operation"
]
},
"language" : "de",
"text" : {
"status" : "extensions"
},
"extension" : [
{
"url" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention",
"code" : "K",
"display" : "kurativ"
}
]
}
}
],
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"category" : {
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{
"system" : "http://snomed.info/sct",
"code" : "387713003",
"display" : "Surgical procedure"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://fhir.de/CodeSystem/bfarm/ops",
"version" : "2024",
"code" : "5-484.55",
"display" : "Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion: Laparoskopisch mit Anastomose"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"encounter" : {
🔗 "reference" : "Encounter/mii-exa-onko-krk-bundle-encounter"
},
"performedDateTime" : "2024-03-22T08:00:00+01:00",
"reasonReference" : [
{
🔗 "reference" : "Condition/mii-exa-onko-krk-diagnose"
}
],
"note" : [
{
"text" : "Laparoskopische Resektion beim kolorektalen Karzinom"
}
]
},
"request" : {
"method" : "POST",
"url" : "Procedure"
}
},
{
"fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Specimen/mii-exa-onko-krk-specimen",
"resource" : {
"resourceType" : "Specimen",
"id" : "mii-exa-onko-krk-specimen",
"meta" : {
"profile" : [
🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-specimen"
]
},
"language" : "de",
"text" : {
"status" : "generated"
},
"accessionIdentifier" : {
"value" : "KRK-2024-001234"
},
"status" : "available",
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "122652004",
"display" : "Specimen from colon obtained by rectal/rectosigmoid (low anterior) resection (specimen)"
}
]
},
"subject" : {
🔗 "reference" : "Patient/mii-exa-onko-krk-bundle-patient"
},
"collection" : {
"collectedDateTime" : "2024-03-22T08:30:00+01:00"
},
"condition" : [
{
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-krk-tme-qualitaet",
"code" : "1",
"display" : "Grad 1 (gut)"
}
]
}
],
"note" : [
{
"text" : "Sigmaresekat mit Primärtumor und regionären Lymphknoten"
}
]
},
"request" : {
"method" : "POST",
"url" : "Specimen"
}
}
]
}