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

: MII EXA Onko KRK Bundle

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="mii-exa-onko-krk-bundle"/>
  <meta>
    <profile value="http://hl7.org/fhir/StructureDefinition/Bundle"/>
  </meta>
  <language value="de"/>
  <identifier>
    <system
            value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko"/>
    <value value="krk-example-bundle-2024-001"/>
  </identifier>
  <type value="transaction"/>
  <timestamp value="2024-03-25T10:00:00+01:00"/>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Patient/mii-exa-onko-krk-bundle-patient"/>
    <resource>
      <Patient>
        <id value="mii-exa-onko-krk-bundle-patient"/>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <name>
          <family value="KolorektalCa"/>
          <given value="Klaus"/>
        </name>
      </Patient>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Patient"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-krk-diagnose"/>
    <resource>
      <Condition>
        <id value="mii-exa-onko-krk-diagnose"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose-primaertumor"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="extensions"/>
        </text>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/condition-assertedDate">
          <valueDateTime value="2020-03-07"/>
        </extension>
        <clinicalStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
            <code value="active"/>
          </coding>
        </clinicalStatus>
        <verificationStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
            <code value="confirmed"/>
          </coding>
        </verificationStatus>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="55342001"/>
            <display value="Neoplastic disease"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://fhir.de/CodeSystem/bfarm/icd-10-gm"/>
            <version value="2024"/>
            <code value="C18"/>
            <display value="Bösartige Neubildung des Kolons"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <recordedDate value="2024-01-02"/>
      </Condition>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Condition"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-krk-bundle-encounter"/>
    <resource>
      <Encounter>
        <id value="mii-exa-onko-krk-bundle-encounter"/>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="finished"/>
        <class>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          <code value="IMP"/>
          <display value="inpatient encounter"/>
        </class>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
      </Encounter>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Encounter"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-abstand-tumor-anokutanlinie"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-krk-abstand-tumor-anokutanlinie"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-abstand-anokutan"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="33748-5"/>
            <display value="Distance from anal verge"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-10T14:30:00+01:00"/>
        <valueQuantity>
          <value value="8.5"/>
          <unit value="cm"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="cm"/>
        </valueQuantity>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-abstand-circumferelle-resektionsebene"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-krk-abstand-circumferelle-resektionsebene"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-abstand-circumferelle-resektionsebene"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="81176-0"/>
            <display
                     value="Distance of tumor from circumferential resection margin [Length] in Specimen by Macroscopy"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-20T10:15:00+01:00"/>
        <valueQuantity>
          <value value="2.5"/>
          <unit value="mm"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mm"/>
        </valueQuantity>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-abstand-resektionsrand-aboral"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-krk-abstand-resektionsrand-aboral"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-abstand-aboral"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="81175-2"/>
            <display
                     value="Distance of tumor from closest margin [Length] in Specimen by Macroscopy"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-20T10:15:00+01:00"/>
        <valueQuantity>
          <value value="15"/>
          <unit value="mm"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mm"/>
        </valueQuantity>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-abstand-mesorektale-fascie"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-krk-abstand-mesorektale-fascie"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-mrt-mesorektale-faszie"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="https://radelement.org"/>
            <code value="RDE96"/>
            <display value="Distance to MRF"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-12T16:00:00+01:00"/>
        <valueQuantity>
          <value value="3.2"/>
          <unit value="mm"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mm"/>
        </valueQuantity>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-krk-anastomoseninsuffizienz"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-krk-anastomoseninsuffizienz"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-anastomoseninsuffizienz"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="236091002"/>
            <display value="Large intestine anastomotic leak (disorder)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Procedure/mii-exa-onko-krk-operation"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-25T08:00:00+01:00"/>
        <valueCodeableConcept>
          <coding>
            <system
                    value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-krk-anastomoseninsuffizienz"/>
            <code value="B"/>
            <display value="Anastomoseninsuffizienz Grad B"/>
          </coding>
        </valueCodeableConcept>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-asa-klassifikation"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-asa-klassifikation"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-asa-klassifikation"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="97816-3"/>
            <display
                     value="American society of anesthesiologists morbidity state"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </focus>
        <effectiveDateTime value="2024-03-15T08:30:00+01:00"/>
        <valueCodeableConcept>
          <coding>
            <system
                    value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-asa-obds"/>
            <code value="2"/>
            <display value="ASA II"/>
          </coding>
        </valueCodeableConcept>
      </Observation>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Observation"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-krk-stoma-markierung"/>
    <resource>
      <Procedure>
        <id value="mii-exa-onko-krk-stoma-markierung"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-stoma-markierung"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="completed"/>
        <statusReason>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="262008008"/>
            <display value="Not performed (qualifier value)"/>
          </coding>
        </statusReason>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="387713003"/>
            <display value="Surgical procedure"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="225134005"/>
            <display
                     value="Marking position of planned stoma site (procedure)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <performedDateTime value="2024-03-15T09:30:00+01:00"/>
        <reasonReference>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </reasonReference>
        <note>
          <text
                value="Präoperative Markierung der geplanten Stoma-Position im rechten Hemiabdomen nach Rücksprache mit dem Patienten"/>
        </note>
      </Procedure>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Procedure"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-krk-operation"/>
    <resource>
      <Procedure>
        <id value="mii-exa-onko-krk-operation"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-operation"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="extensions"/>
        </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="5-484.55"/>
            <display
                     value="Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion: Laparoskopisch mit Anastomose"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-krk-bundle-encounter"/>
        </encounter>
        <performedDateTime value="2024-03-22T08:00:00+01:00"/>
        <reasonReference>🔗 
          <reference value="Condition/mii-exa-onko-krk-diagnose"/>
        </reasonReference>
        <note>
          <text value="Laparoskopische Resektion beim kolorektalen Karzinom"/>
        </note>
      </Procedure>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Procedure"/>
    </request>
  </entry>
  <entry>
    <fullUrl
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Specimen/mii-exa-onko-krk-specimen"/>
    <resource>
      <Specimen>
        <id value="mii-exa-onko-krk-specimen"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-krk-specimen"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <accessionIdentifier>
          <value value="KRK-2024-001234"/>
        </accessionIdentifier>
        <status value="available"/>
        <type>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="122652004"/>
            <display
                     value="Specimen from colon obtained by rectal/rectosigmoid (low anterior) resection (specimen)"/>
          </coding>
        </type>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-krk-bundle-patient"/>
        </subject>
        <collection>
          <collectedDateTime value="2024-03-22T08:30:00+01:00"/>
        </collection>
        <condition>
          <coding>
            <system
                    value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-krk-tme-qualitaet"/>
            <code value="1"/>
            <display value="Grad 1 (gut)"/>
          </coding>
        </condition>
        <note>
          <text
                value="Sigmaresekat mit Primärtumor und regionären Lymphknoten"/>
        </note>
      </Specimen>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Specimen"/>
    </request>
  </entry>
</Bundle>