Kerndatensatz Senologie
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: Fall 12: ADH (B3-Läsion), D48.6 - JSON Representation

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{
  "resourceType" : "Condition",
  "id" : "Fall12-Diagnose-ADH",
  "meta" : {
    "profile" : [
      🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-diagnose-maligne"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Condition Fall12-Diagnose-ADH</b></p><a name=\"Fall12-Diagnose-ADH\"> </a><a name=\"hcFall12-Diagnose-ADH\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-senologie-diagnose-maligne.html\">BIH PR Seno Diagnose Maligne</a></p></div><p><b>Condition Asserted Date</b>: 2025-07-15</p><p><b>clinicalStatus</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}\">Active</span></p><p><b>verificationStatus</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/condition-ver-status confirmed}, {https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-primaertumor-diagnosesicherung 7}\">histologische Untersuchung eines Primärtumors</span></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 269497004}, {http://fhir.de/CodeSystem/bfarm/icd-10-gm D48.6}\">Atypische duktale Hyperplasie (ADH), B3-Läsion</span></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 80248007}\">Left breast structure</span></p><p><b>subject</b>: <a href=\"Patient-Fall12-Patient-Renate-Vogel.html\">Renate Vogel  Female, DoB: 1981-03-06 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-012)</a></p><p><b>onset</b>: 2025-07-15</p><p><b>recordedDate</b>: 2025-07-15</p></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/condition-assertedDate",
      "valueDateTime" : "2025-07-15"
    }
  ],
  "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",
        "display" : "histologische Untersuchung eines Primärtumors"
      }
    ]
  },
  "code" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "269497004",
        "display" : "Neoplasm of uncertain behavior of breast"
      },
      {
        "system" : "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
        "version" : "2025",
        "code" : "D48.6",
        "display" : "Neubildung unsicheren oder unbekannten Verhaltens: Brustdrüse [Mamma]"
      }
    ],
    "text" : "Atypische duktale Hyperplasie (ADH), B3-Läsion"
  },
  "bodySite" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "80248007",
          "display" : "Left breast structure"
        }
      ]
    }
  ],
  "subject" : {
    🔗 "reference" : "Patient/Fall12-Patient-Renate-Vogel"
  },
  "onsetDateTime" : "2025-07-15",
  "recordedDate" : "2025-07-15"
}