{ "resourceType" : "QuestionnaireResponse", "id" : "QuestionnaireResponseCoreNeedleBiopsy", "text" : { "status" : "generated", "div" : "

Generated Narrative: QuestionnaireResponse QuestionnaireResponseCoreNeedleBiopsy

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LinkIDTextDefinitionAnswer\"doco\"
\".\"\".\" QuestionnaireResponseCoreNeedleBiopsyQuestionnaire:http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy
\".\"\".\"\".\" cnb.rootStanzbiopsie Mamma
\".\"\".\"\".\"\".\" cnb.patientPatientendaten
\".\"\".\"\".\"\".\"\".\" cnb.patient.nameFamiliennameBecker
\".\"\".\"\".\"\".\"\".\" cnb.patient.givenVornameSabine
\".\"\".\"\".\"\".\"\".\" cnb.patient.dobGeburtsdatum1971-03-15
\".\"\".\"\".\"\".\"\".\" cnb.patient.idPatienten-IdentifikatorPAT-2025-105
\".\"\".\"\".\"\".\" cnb.clinicalKlinische Angaben
\".\"\".\"\".\"\".\"\".\" cnb.clinical.indicationUntersuchungsanlassHerdbefund/Architekturstörung linke Brust
\".\"\".\"\".\"\".\"\".\" cnb.clinical.biradsBI-RADS4b
\".\"\".\"\".\"\".\"\".\" cnb.clinical.imagingBildgebungsmodalitätUltraschall
\".\"\".\"\".\"\".\" cnb.specimenUntersuchungsmaterial
\".\"\".\"\".\"\".\"\".\" cnb.specimen.typeMaterialartHG-Stanzen/Mamma
\".\"\".\"\".\"\".\"\".\" cnb.specimen.sideSeitenlokalisationSNOMED CT: 7771000 (Left (qualifier value))
\".\"\".\"\".\"\".\"\".\" cnb.specimen.clockUhrzeigerlokalisation5 Uhr
\".\"\".\"\".\"\".\"\".\" cnb.specimen.distanceAbstand von Mamille5 cm (Details: UCUM codecm = 'cm')
\".\"\".\"\".\"\".\"\".\" cnb.specimen.lengthGesamtlänge der Stanzzylinder22 mm (Details: UCUM codemm = 'mm')
\".\"\".\"\".\"\".\"\".\" cnb.specimen.cylindersAnzahl Stanzzylinder2
\".\"\".\"\".\"\".\"\".\" cnb.specimen.blocksAnzahl Blöcke1
\".\"\".\"\".\"\".\" cnb.histologyHistologischer Tumortyp
\".\"\".\"\".\"\".\"\".\" cnb.histology.icdo3Histologischer Typ ICD-O-3unknown: 8500/3 (Invasives duktales Karzinom (NST))
\".\"\".\"\".\"\".\" cnb.gradingNottingham-Grading
\".\"\".\"\".\"\".\"\".\" cnb.grading.gradeNottingham-GradG2
\".\"\".\"\".\"\".\"\".\" cnb.grading.scoreElston-Ellis Summenscore6
\".\"\".\"\".\"\".\"\".\" cnb.grading.tubulesTubulusbildung3
\".\"\".\"\".\"\".\"\".\" cnb.grading.pleomorphismKernpleomorphie2
\".\"\".\"\".\"\".\"\".\" cnb.grading.mitosesMitoserate1
\".\"\".\"\".\"\".\" cnb.biomarkersBiomarker
\".\"\".\"\".\"\".\"\".\" cnb.biomarkers.erÖstrogenrezeptorSNOMED CT: 52101004 (Present (qualifier value))
\".\"\".\"\".\"\".\"\".\" cnb.biomarkers.er.pctER Prozent85
\".\"\".\"\".\"\".\"\".\" cnb.biomarkers.prProgesteronrezeptorSNOMED CT: 52101004 (Present (qualifier value))
\".\"\".\"\".\"\".\"\".\" cnb.biomarkers.pr.pctPR Prozent50
\".\"\".\"\".\"\".\"\".\" cnb.biomarkers.her2HER2 AmplifikationNegativ (nicht amplifiziert)
\".\"\".\"\".\"\".\"\".\" cnb.biomarkers.ki67Ki-6710
\".\"\".\"\".\"\".\" cnb.bclassificationB-Klassifikation
\".\"\".\"\".\"\".\"\".\" cnb.bclassification.valueB-Klassifikation (NHSBSP)B5b
\".\"\".\"\".\"\".\" cnb.microcalcificationMikroverkalkungen
\".\"\".\"\".\"\".\"\".\" cnb.microcalcification.relevantRelevante MikroverkalkungenSNOMED CT: 2667000 (Absent (qualifier value))
\".\"\".\"\".\"\".\"\".\" cnb.microcalcification.radiographyPräparateradiogrammGesehen
\".\"\".\"\".\"\".\"\".\" cnb.microcalcification.correlationKorrelation MikroverkalkungVorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer)

\"doco\" Documentation for this format
" }, "questionnaire" : "http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy", "status" : "completed", "subject" : { "reference" : "Patient/Patient4" }, "authored" : "2025-01-17T14:30:00+01:00", "author" : { "reference" : "Practitioner/PathologistPractitioner" }, "item" : [{ "linkId" : "cnb.root", "text" : "Stanzbiopsie Mamma", "item" : [{ "linkId" : "cnb.patient", "text" : "Patientendaten", "item" : [{ "linkId" : "cnb.patient.name", "text" : "Familienname", "answer" : [{ "valueString" : "Becker" }] }, { "linkId" : "cnb.patient.given", "text" : "Vorname", "answer" : [{ "valueString" : "Sabine" }] }, { "linkId" : "cnb.patient.dob", "text" : "Geburtsdatum", "answer" : [{ "valueDate" : "1971-03-15" }] }, { "linkId" : "cnb.patient.id", "text" : "Patienten-Identifikator", "answer" : [{ "valueString" : "PAT-2025-105" }] }] }, { "linkId" : "cnb.clinical", "text" : "Klinische Angaben", "item" : [{ "linkId" : "cnb.clinical.indication", "text" : "Untersuchungsanlass", "answer" : [{ "valueString" : "Herdbefund/Architekturstörung linke Brust" }] }, { "linkId" : "cnb.clinical.birads", "text" : "BI-RADS", "answer" : [{ "valueString" : "4b" }] }, { "linkId" : "cnb.clinical.imaging", "text" : "Bildgebungsmodalität", "answer" : [{ "valueString" : "Ultraschall" }] }] }, { "linkId" : "cnb.specimen", "text" : "Untersuchungsmaterial", "item" : [{ "linkId" : "cnb.specimen.type", "text" : "Materialart", "answer" : [{ "valueString" : "HG-Stanzen/Mamma" }] }, { "linkId" : "cnb.specimen.side", "text" : "Seitenlokalisation", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "7771000", "display" : "Left (qualifier value)" } }] }, { "linkId" : "cnb.specimen.clock", "text" : "Uhrzeigerlokalisation", "answer" : [{ "valueString" : "5 Uhr" }] }, { "linkId" : "cnb.specimen.distance", "text" : "Abstand von Mamille", "answer" : [{ "valueQuantity" : { "value" : 5, "unit" : "cm", "system" : "http://unitsofmeasure.org", "code" : "cm" } }] }, { "linkId" : "cnb.specimen.length", "text" : "Gesamtlänge der Stanzzylinder", "answer" : [{ "valueQuantity" : { "value" : 22, "unit" : "mm", "system" : "http://unitsofmeasure.org", "code" : "mm" } }] }, { "linkId" : "cnb.specimen.cylinders", "text" : "Anzahl Stanzzylinder", "answer" : [{ "valueInteger" : 2 }] }, { "linkId" : "cnb.specimen.blocks", "text" : "Anzahl Blöcke", "answer" : [{ "valueInteger" : 1 }] }] }, { "linkId" : "cnb.histology", "text" : "Histologischer Tumortyp", "item" : [{ "linkId" : "cnb.histology.icdo3", "text" : "Histologischer Typ ICD-O-3", "answer" : [{ "valueCoding" : { "system" : "urn:oid:2.16.840.1.113883.6.43.1", "code" : "8500/3", "display" : "Invasives duktales Karzinom (NST)" } }] }] }, { "linkId" : "cnb.grading", "text" : "Nottingham-Grading", "item" : [{ "linkId" : "cnb.grading.grade", "text" : "Nottingham-Grad", "answer" : [{ "valueString" : "G2" }] }, { "linkId" : "cnb.grading.score", "text" : "Elston-Ellis Summenscore", "answer" : [{ "valueInteger" : 6 }] }, { "linkId" : "cnb.grading.tubules", "text" : "Tubulusbildung", "answer" : [{ "valueInteger" : 3 }] }, { "linkId" : "cnb.grading.pleomorphism", "text" : "Kernpleomorphie", "answer" : [{ "valueInteger" : 2 }] }, { "linkId" : "cnb.grading.mitoses", "text" : "Mitoserate", "answer" : [{ "valueInteger" : 1 }] }] }, { "linkId" : "cnb.biomarkers", "text" : "Biomarker", "item" : [{ "linkId" : "cnb.biomarkers.er", "text" : "Östrogenrezeptor", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "52101004", "display" : "Present (qualifier value)" } }] }, { "linkId" : "cnb.biomarkers.er.pct", "text" : "ER Prozent", "answer" : [{ "valueInteger" : 85 }] }, { "linkId" : "cnb.biomarkers.pr", "text" : "Progesteronrezeptor", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "52101004", "display" : "Present (qualifier value)" } }] }, { "linkId" : "cnb.biomarkers.pr.pct", "text" : "PR Prozent", "answer" : [{ "valueInteger" : 50 }] }, { "linkId" : "cnb.biomarkers.her2", "text" : "HER2 Amplifikation", "answer" : [{ "valueString" : "Negativ (nicht amplifiziert)" }] }, { "linkId" : "cnb.biomarkers.ki67", "text" : "Ki-67", "answer" : [{ "valueInteger" : 10 }] }] }, { "linkId" : "cnb.bclassification", "text" : "B-Klassifikation", "item" : [{ "linkId" : "cnb.bclassification.value", "text" : "B-Klassifikation (NHSBSP)", "answer" : [{ "valueString" : "B5b" }] }] }, { "linkId" : "cnb.microcalcification", "text" : "Mikroverkalkungen", "item" : [{ "linkId" : "cnb.microcalcification.relevant", "text" : "Relevante Mikroverkalkungen", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "2667000", "display" : "Absent (qualifier value)" } }] }, { "linkId" : "cnb.microcalcification.radiography", "text" : "Präparateradiogramm", "answer" : [{ "valueString" : "Gesehen" }] }, { "linkId" : "cnb.microcalcification.correlation", "text" : "Korrelation Mikroverkalkung", "answer" : [{ "valueString" : "Vorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer)" }] }] }] }] }