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

Example Bundle: FOLFOX Workflow Bundle - Komplettes Beispiel von Tumorkonferenz bis Therapie

Language: en

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

Resource Patient:


English


Generated Narrative: Patient mii-exa-onko-folfox-patient

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

Resource Encounter:


English


Generated Narrative: Encounter mii-exa-onko-folfox-encounter-diagnosis

status: Finished

class: ActCode: AMB (ambulatory)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)


Entry 3 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-folfox-encounter-surgery

Resource Encounter:


English


Generated Narrative: Encounter mii-exa-onko-folfox-encounter-surgery

status: Finished

class: ActCode: IMP (inpatient encounter)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)


Entry 4 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-folfox-encounter-chemo

Resource Encounter:


English


Generated Narrative: Encounter mii-exa-onko-folfox-encounter-chemo

status: Finished

class: ActCode: AMB (ambulatory)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)


Entry 5 - fullUrl = https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-colorectal-cancer-diagnosis

Resource Condition:


English


Generated Narrative: Condition mii-exa-onko-colorectal-cancer-diagnosis

Condition Asserted Date: 2024-01-15

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis, Neoplastic disease

code: Bösartige Neubildung: Colon sigmoideum

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Observation:


English


Generated Narrative: Observation mii-exa-onko-colorectal-tnm-t

Profile: MII PR Onkologie TNM T-Kategorie version: 2027.0.0-ballot.1

status: Final

code: pT category (observable entity)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Observation:


English


Generated Narrative: Observation mii-exa-onko-colorectal-tnm-n

Profile: MII PR Onkologie TNM N-Kategorie version: 2027.0.0-ballot.1

status: Final

code: pN category (observable entity)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Observation:


English


Generated Narrative: Observation mii-exa-onko-colorectal-tnm-m

Profile: MII PR Onkologie TNM M-Kategorie version: 2027.0.0-ballot.1

status: Final

code: cM category (observable entity)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Observation:


English


Generated Narrative: Observation mii-exa-onko-colorectal-tnm

status: Final

code: Pathologic TNM stage grouping

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource CarePlan:


English


Generated Narrative: CarePlan mii-exa-onko-tumorkonferenz-folfox

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)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

created: 2024-03-10

addresses: Condition Bösartige Neubildung: Colon sigmoideum

Activities

-ProgressReference
*

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

Resource RequestGroup:


English


Generated Narrative: RequestGroup mii-exa-onko-folfox-requestgroup

status: Active

intent: Proposal

code: Chemotherapie

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

authoredOn: 2024-03-10

reasonReference: Condition Bösartige Neubildung: Colon sigmoideum

action

title: FOLFOX4 Protocol

description: FOLFOX4 chemotherapy protocol: Fluorouracil + Folinsäure + Oxaliplatin

code: FOLFOX4

Actions

-TitleDescriptionResource
*Fluorouracil (5-FU)5-Fluorouracil - pyrimidine analog, antineoplasticMedicationRequest: status = active; intent = proposal; medication[x] = Fluorouracil; authoredOn = 2024-03-10
*Folinsäure (Leucovorin)Folinic acid - enhances 5-FU efficacyMedicationRequest: status = active; intent = proposal; medication[x] = Calciumfolinat; authoredOn = 2024-03-10
*OxaliplatinPlatinum-based chemotherapy agentMedicationRequest: 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

Resource MedicationRequest:


English


Generated Narrative: MedicationRequest mii-exa-onko-folfox-5fu-request

Profile: MII PR Onkologie Therapieempfehlung Medikation version: 2027.0.0-ballot.1

status: Active

intent: Proposal

medication: 5-Fluorouracil (5-FU)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource MedicationRequest:


English


Generated Narrative: MedicationRequest mii-exa-onko-folfox-leucovorin-request

Profile: MII PR Onkologie Therapieempfehlung Medikation version: 2027.0.0-ballot.1

status: Active

intent: Proposal

medication: Leucovorin (Folinsäure)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource MedicationRequest:


English


Generated Narrative: MedicationRequest mii-exa-onko-folfox-oxaliplatin-request

Profile: MII PR Onkologie Therapieempfehlung Medikation version: 2027.0.0-ballot.1

status: Active

intent: Proposal

medication: Oxaliplatin

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Procedure:


English


Generated Narrative: Procedure mii-exa-onko-sigmoid-resection

MII EX Onko Operation Intention: Kurativ

status: Completed

category: Surgical procedure

code: Laparoskopische Sigmaresektion mit TME und Lymphknotendissektion

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Procedure:


English


Generated Narrative: Procedure mii-exa-onko-sigmoid-resection-part1

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

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Procedure:


English


Generated Narrative: Procedure mii-exa-onko-sigmoid-resection-part2

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

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Procedure:


English


Generated Narrative: Procedure mii-exa-onko-sigmoid-resection-part3

MII EX Onko Operation Intention: Kurativ

partOf: Procedure Rektumresektion unter Sphinktererhaltung: Tiefe anteriore Resektion

status: Completed

category: Surgical procedure

code: Minimalinvasive Technik: Sonstige

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Procedure:


English


Generated Narrative: Procedure mii-exa-onko-folfox-procedure

MII EX Onko Systemische Therapie Intention: Kurativ

MII EX Onko Systemische Therapie Stellung zur OP: Adjuvant

basedOn: CarePlan: identifier = Tumorkonferenz_FOLFOX_001; status = active; intent = plan; category = prätherapeutische Tumorkonferenz (Festlegung der Therapiestrategie); created = 2024-03-10

status: Completed

category: Therapeutic procedure

code: Nicht komplexe Chemotherapie

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource MedicationStatement:


English


Generated Narrative: MedicationStatement mii-exa-onko-folfox-5fu-statement

basedOn: CarePlan: identifier = Tumorkonferenz_FOLFOX_001; status = active; intent = plan; category = prätherapeutische Tumorkonferenz (Festlegung der Therapiestrategie); created = 2024-03-10

partOf: Procedure Nicht komplexe Chemotherapie

status: Completed

medication: 5-Fluorouracil (5-FU)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource MedicationStatement:


English


Generated Narrative: MedicationStatement mii-exa-onko-folfox-leucovorin-statement

basedOn: CarePlan: identifier = Tumorkonferenz_FOLFOX_001; status = active; intent = plan; category = prätherapeutische Tumorkonferenz (Festlegung der Therapiestrategie); created = 2024-03-10

partOf: Procedure Nicht komplexe Chemotherapie

status: Completed

medication: Leucovorin (Folinsäure)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource MedicationStatement:


English


Generated Narrative: MedicationStatement mii-exa-onko-folfox-oxaliplatin-statement

basedOn: CarePlan: identifier = Tumorkonferenz_FOLFOX_001; status = active; intent = plan; category = prätherapeutische Tumorkonferenz (Festlegung der Therapiestrategie); created = 2024-03-10

partOf: Procedure Nicht komplexe Chemotherapie

status: Completed

medication: Oxaliplatin

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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

Resource Observation:


English


Generated Narrative: Observation mii-exa-onko-folfox-verlauf-6months

status: Final

code: Status of regression of tumor (observable entity)

subject: Hans Schmidt Male, DoB: 1959-03-15 ( https://www.medizininformatik-initiative.de/fhir/sid/patienten#FOLFOX-2024-001)

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