{ "resourceType" : "Bundle", "id" : "mii-exa-onko-melanom-bundle", "meta" : { "profile" : ["http://hl7.org/fhir/StructureDefinition/Bundle"] }, "language" : "en", "identifier" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko", "value" : "melanom-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-melanom-bundle-patient", "resource" : { "resourceType" : "Patient", "id" : "mii-exa-onko-melanom-bundle-patient", "language" : "en", "text" : { "status" : "generated", "div" : "

English

Generated Narrative: Patient mii-exa-onko-melanom-bundle-patient

Maria Melanom (no stated gender), DoB Unknown

" }, "name" : [{ "family" : "Melanom", "given" : ["Maria"] }] }, "request" : { "method" : "POST", "url" : "Patient" } }, { "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Condition/mii-exa-onko-melanom-diagnose", "resource" : { "resourceType" : "Condition", "id" : "mii-exa-onko-melanom-diagnose", "meta" : { "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-diagnose-primaertumor|2027.0.0-ballot.1"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

English

Generated Narrative: Condition mii-exa-onko-melanom-diagnose

Profile: MII PR Onkologie Diagnose Primärtumor version: 2027.0.0-ballot.1

Condition Asserted Date: 2024-01-02

clinicalStatus: Active

verificationStatus: histologische Untersuchung eines Primärtumors

category: Neoplastic disease

code: Bösartiges Melanom der Haut, nicht näher bezeichnet

subject: Maria Melanom (no stated gender), DoB Unknown

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)

recordedDate: 2024-01-02

" }, "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/condition-assertedDate", "valueDateTime" : "2024-01-02" }], "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" }, { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-primaertumor-diagnosesicherung", "code" : "7.1", "display" : "histologische Untersuchung eines Primärtumors" }] }, "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" : "C43.9", "display" : "Bösartiges Melanom der Haut, nicht näher bezeichnet" }] }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" }, "encounter" : { "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter" }, "recordedDate" : "2024-01-02" }, "request" : { "method" : "POST", "url" : "Condition" } }, { "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Encounter/mii-exa-onko-melanom-bundle-encounter", "resource" : { "resourceType" : "Encounter", "id" : "mii-exa-onko-melanom-bundle-encounter", "language" : "en", "text" : { "status" : "generated", "div" : "

English

Generated Narrative: Encounter mii-exa-onko-melanom-bundle-encounter

status: Finished

class: ActCode: IMP (inpatient encounter)

subject: Maria Melanom (no stated gender), DoB Unknown

" }, "status" : "finished", "class" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code" : "IMP", "display" : "inpatient encounter" }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" } }, "request" : { "method" : "POST", "url" : "Encounter" } }, { "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-sicherheitsabstand", "resource" : { "resourceType" : "Observation", "id" : "mii-exa-onko-melanom-sicherheitsabstand", "meta" : { "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-sicherheitsabstand"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

English

Generated Narrative: Observation mii-exa-onko-melanom-sicherheitsabstand

Profile: MII PR Onkologie Melanom Sicherheitsabstand

status: Final

code: Distance of in situ melanoma from closest lateral surgical margin in excised specimen of skin (observable entity)

subject: Maria Melanom (no stated gender), DoB Unknown

focus: Condition Bösartiges Melanom der Haut, nicht näher bezeichnet

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)

effective: 2024-03-25 10:00:00+0100

value: 5 mm (Details: UCUM codemm = 'mm')

" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "396511007", "display" : "Distance of in situ melanoma from closest lateral surgical margin in excised specimen of skin (observable entity)" }] }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" }, "focus" : [{ "reference" : "Condition/mii-exa-onko-melanom-diagnose" }], "encounter" : { "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter" }, "effectiveDateTime" : "2024-03-25T10:00:00+01:00", "valueQuantity" : { "value" : 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-melanom-breslow-tiefe", "resource" : { "resourceType" : "Observation", "id" : "mii-exa-onko-melanom-breslow-tiefe", "meta" : { "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-breslow-tiefe"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

English

Generated Narrative: Observation mii-exa-onko-melanom-breslow-tiefe

Profile: MII PR Onkologie Melanom Breslow Tiefe

status: Final

code: Breslow depth staging for melanoma of skin (observable entity)

subject: Maria Melanom (no stated gender), DoB Unknown

focus: Condition Bösartiges Melanom der Haut, nicht näher bezeichnet

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)

effective: 2024-03-20 14:30:00+0100

value: 2.1 mm (Details: UCUM codemm = 'mm')

method: Immunohistochemistry procedure

" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "106243009", "display" : "Breslow depth staging for melanoma of skin (observable entity)" }] }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" }, "focus" : [{ "reference" : "Condition/mii-exa-onko-melanom-diagnose" }], "encounter" : { "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter" }, "effectiveDateTime" : "2024-03-20T14:30:00+01:00", "valueQuantity" : { "value" : 2.1, "unit" : "mm", "system" : "http://unitsofmeasure.org", "code" : "mm" }, "method" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "117617002", "display" : "Immunohistochemistry procedure" }] } }, "request" : { "method" : "POST", "url" : "Observation" } }, { "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-ulzeration", "resource" : { "resourceType" : "Observation", "id" : "mii-exa-onko-melanom-ulzeration", "meta" : { "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-ulzeration"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

English

Generated Narrative: Observation mii-exa-onko-melanom-ulzeration

Profile: MII PR Onkologie Melanom Ulzeration

status: Final

code: Presence of ulcer in primary malignant melanoma of skin (observable entity)

subject: Maria Melanom (no stated gender), DoB Unknown

focus: Condition Bösartiges Melanom der Haut, nicht näher bezeichnet

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)

effective: 2024-03-20 14:30:00+0100

value: Ja

method: Immunohistochemistry procedure

" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "6270001000004106", "display" : "Presence of ulcer in primary malignant melanoma of skin (observable entity)" }] }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" }, "focus" : [{ "reference" : "Condition/mii-exa-onko-melanom-diagnose" }], "encounter" : { "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter" }, "effectiveDateTime" : "2024-03-20T14:30:00+01:00", "valueCodeableConcept" : { "coding" : [{ "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-melanom-ulzeration", "code" : "J", "display" : "Ja" }] }, "method" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "117617002", "display" : "Immunohistochemistry procedure" }] } }, "request" : { "method" : "POST", "url" : "Observation" } }, { "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Observation/mii-exa-onko-melanom-ldh", "resource" : { "resourceType" : "Observation", "id" : "mii-exa-onko-melanom-ldh", "meta" : { "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-ldh"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

English

Generated Narrative: Observation mii-exa-onko-melanom-ldh

Profile: MII PR Onkologie Melanom LDH

status: Final

category: Laboratory

code: Lactate dehydrogenase [Enzymatic activity/volume] in Serum or Plasma by Lactate to pyruvate reaction

subject: Maria Melanom (no stated gender), DoB Unknown

focus: Condition Bösartiges Melanom der Haut, nicht näher bezeichnet

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP)

effective: 2024-03-18 08:30:00+0100

value: 280 U/L (Details: UCUM codeU/L = 'U/L')

interpretation: High

ReferenceRanges

-LowHighText
*135 U/L (Details: UCUM codeU/L = 'U/L')250 U/L (Details: UCUM codeU/L = 'U/L')135-250 U/L
" }, "status" : "final", "category" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/observation-category", "code" : "laboratory", "display" : "Laboratory" }] }], "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "14804-9", "display" : "Lactate dehydrogenase [Enzymatic activity/volume] in Serum or Plasma by Lactate to pyruvate reaction" }] }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" }, "focus" : [{ "reference" : "Condition/mii-exa-onko-melanom-diagnose" }], "encounter" : { "reference" : "Encounter/mii-exa-onko-melanom-bundle-encounter" }, "effectiveDateTime" : "2024-03-18T08:30:00+01:00", "valueQuantity" : { "value" : 280, "unit" : "U/L", "system" : "http://unitsofmeasure.org", "code" : "U/L" }, "interpretation" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code" : "H", "display" : "High" }] }], "referenceRange" : [{ "low" : { "value" : 135, "unit" : "U/L", "system" : "http://unitsofmeasure.org", "code" : "U/L" }, "high" : { "value" : 250, "unit" : "U/L", "system" : "http://unitsofmeasure.org", "code" : "U/L" }, "text" : "135-250 U/L" }] }, "request" : { "method" : "POST", "url" : "Observation" } }, { "fullUrl" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/Procedure/mii-exa-onko-melanom-exzision-oberarm", "resource" : { "resourceType" : "Procedure", "id" : "mii-exa-onko-melanom-exzision-oberarm", "meta" : { "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-melanom-exzision|2027.0.0-ballot.1"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

English

Generated Narrative: Procedure mii-exa-onko-melanom-exzision-oberarm

Profile: MII PR Onko Melanom Exzision version: 2027.0.0-ballot.1

MII EX Onko Operation Intention: kurativ

status: Completed

category: Surgical procedure

code: Lokale Exzision von erkranktem Gewebe an Haut und Unterhaut: Ohne primären Wundverschluss: Schulter und Axilla

subject: Maria Melanom (no stated gender), DoB Unknown

performed: 2024-03-20

reasonReference: Condition Bösartiges Melanom der Haut, nicht näher bezeichnet

bodySite: Left upper arm structure

outcome: Kein Residualtumor

" }, "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" }] } }], "status" : "completed", "category" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "387713003", "display" : "Surgical procedure" }] }, "code" : { "coding" : [{ "system" : "http://fhir.de/CodeSystem/bfarm/ops", "version" : "2024", "code" : "5-894.06", "display" : "Lokale Exzision von erkranktem Gewebe an Haut und Unterhaut: Ohne primären Wundverschluss: Schulter und Axilla" }, { "system" : "http://snomed.info/sct", "code" : "177281002", "display" : "Excision of melanoma (procedure)" }] }, "subject" : { "reference" : "Patient/mii-exa-onko-melanom-bundle-patient" }, "performedDateTime" : "2024-03-20", "reasonReference" : [{ "reference" : "Condition/mii-exa-onko-melanom-diagnose" }], "bodySite" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "368208006", "display" : "Left upper arm structure" }] }], "outcome" : { "coding" : [{ "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus", "code" : "R0", "display" : "Kein Residualtumor" }] } }, "request" : { "method" : "POST", "url" : "Procedure" } }] }