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 Melanom Bundle

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="mii-exa-onko-melanom-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="melanom-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-melanom-bundle-patient"/>
    <resource>
      <Patient>
        <id value="mii-exa-onko-melanom-bundle-patient"/>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <name>
          <family value="Melanom"/>
          <given value="Maria"/>
        </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-melanom-diagnose"/>
    <resource>
      <Condition>
        <id value="mii-exa-onko-melanom-diagnose"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose-primaertumor|2027.0.0-ballot.1"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="extensions"/>
        </text>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/condition-assertedDate">
          <valueDateTime value="2024-01-02"/>
        </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>
          <coding>
            <system
                    value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-primaertumor-diagnosesicherung"/>
            <code value="7.1"/>
            <display value="histologische Untersuchung eines Primärtumors"/>
          </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="C43.9"/>
            <display
                     value="Bösartiges Melanom der Haut, nicht näher bezeichnet"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-melanom-bundle-patient"/>
        </subject>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-melanom-bundle-encounter"/>
        </encounter>
        <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-melanom-bundle-encounter"/>
    <resource>
      <Encounter>
        <id value="mii-exa-onko-melanom-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-melanom-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-melanom-sicherheitsabstand"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-melanom-sicherheitsabstand"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-sicherheitsabstand"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="396511007"/>
            <display
                     value="Distance of in situ melanoma from closest lateral surgical margin in excised specimen of skin (observable entity)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-melanom-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-melanom-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-melanom-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-25T10:00:00+01:00"/>
        <valueQuantity>
          <value value="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-melanom-breslow-tiefe"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-melanom-breslow-tiefe"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-breslow-tiefe"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="106243009"/>
            <display
                     value="Breslow depth staging for melanoma of skin (observable entity)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-melanom-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-melanom-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-melanom-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-20T14:30:00+01:00"/>
        <valueQuantity>
          <value value="2.1"/>
          <unit value="mm"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mm"/>
        </valueQuantity>
        <method>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="117617002"/>
            <display value="Immunohistochemistry procedure"/>
          </coding>
        </method>
      </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-melanom-ulzeration"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-melanom-ulzeration"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-ulzeration"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="6270001000004106"/>
            <display
                     value="Presence of ulcer in primary malignant melanoma of skin (observable entity)"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-melanom-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-melanom-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-melanom-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-20T14:30:00+01:00"/>
        <valueCodeableConcept>
          <coding>
            <system
                    value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-melanom-ulzeration"/>
            <code value="J"/>
            <display value="Ja"/>
          </coding>
        </valueCodeableConcept>
        <method>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="117617002"/>
            <display value="Immunohistochemistry procedure"/>
          </coding>
        </method>
      </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-melanom-ldh"/>
    <resource>
      <Observation>
        <id value="mii-exa-onko-melanom-ldh"/>
        <meta>
          <profile
                   value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-ldh"/>
        </meta>
        <language value="de"/>
        <text>
          <status value="generated"/>
        </text>
        <status value="final"/>
        <category>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/observation-category"/>
            <code value="laboratory"/>
            <display value="Laboratory"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="14804-9"/>
            <display
                     value="Lactate dehydrogenase [Enzymatic activity/volume] in Serum or Plasma by Lactate to pyruvate reaction"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/mii-exa-onko-melanom-bundle-patient"/>
        </subject>
        <focus>🔗 
          <reference value="Condition/mii-exa-onko-melanom-diagnose"/>
        </focus>
        <encounter>🔗 
          <reference value="Encounter/mii-exa-onko-melanom-bundle-encounter"/>
        </encounter>
        <effectiveDateTime value="2024-03-18T08:30:00+01:00"/>
        <valueQuantity>
          <value value="280"/>
          <unit value="U/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="U/L"/>
        </valueQuantity>
        <interpretation>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
            <code value="H"/>
            <display value="High"/>
          </coding>
        </interpretation>
        <referenceRange>
          <low>
            <value value="135"/>
            <unit value="U/L"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="U/L"/>
          </low>
          <high>
            <value value="250"/>
            <unit value="U/L"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="U/L"/>
          </high>
          <text value="135-250 U/L"/>
        </referenceRange>
      </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-melanom-exzision-oberarm"/>
    <resource>
      <Procedure>
        <id value="mii-exa-onko-melanom-exzision-oberarm"/>
        <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"/>
        </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="5-894.06"/>
            <display
                     value="Lokale Exzision von erkranktem Gewebe an Haut und Unterhaut: Ohne primären Wundverschluss: Schulter und Axilla"/>
          </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="2024-03-20"/>
        <reasonReference>🔗 
          <reference value="Condition/mii-exa-onko-melanom-diagnose"/>
        </reasonReference>
        <bodySite>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="368208006"/>
            <display value="Left upper arm structure"/>
          </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>
      </Procedure>
    </resource>
    <request>
      <method value="POST"/>
      <url value="Procedure"/>
    </request>
  </entry>
</Bundle>