Kerndatensatz Senologie - Local Development build (v0.9.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Fall 11: Klinische Brustuntersuchung - JSON Representation

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{
  "resourceType" : "Observation",
  "id" : "Fall11-Klinische-Untersuchung",
  "meta" : {
    "profile" : [
      🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-klinische-untersuchung"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Observation Fall11-Klinische-Untersuchung</b></p><a name=\"Fall11-Klinische-Untersuchung\"> </a><a name=\"hcFall11-Klinische-Untersuchung\"> </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-klinische-untersuchung.html\">BIH Senologie Klinische Untersuchung</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 32422-8}\">Physical findings of Breast</span></p><p><b>subject</b>: <a href=\"Patient-Fall11-Patient-Hannah-Klein.html\">Hannah Klein  Female, DoB: 1991-08-23 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-011)</a></p><p><b>effective</b>: 2025-09-01</p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 80248007}\">Left breast structure</span></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 118242002}\">Finding by palpation</span></p><p><b>value</b>: Tastbarer Knoten links oben außen, ca. 15 mm, glatt begrenzt, verschieblich, nicht druckschmerzhaft</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 115951000119105}\">Breast symptom of change in skin</span></p><p><b>value</b>: Keine Hautveränderungen</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 248819006}\">Nipple finding</span></p><p><b>value</b>: Mamille unauffällig, keine Sekretion</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 301782006}\">Finding of lymph node of axillary region</span></p><p><b>value</b>: Axilläre Lymphknoten beidseits unauffällig</p></blockquote></div>"
  },
  "status" : "final",
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "32422-8",
        "display" : "Physical findings of Breast"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/Fall11-Patient-Hannah-Klein"
  },
  "effectiveDateTime" : "2025-09-01",
  "bodySite" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "80248007",
        "display" : "Left breast structure"
      }
    ]
  },
  "component" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "118242002",
            "display" : "Finding by palpation"
          }
        ]
      },
      "valueString" : "Tastbarer Knoten links oben außen, ca. 15 mm, glatt begrenzt, verschieblich, nicht druckschmerzhaft"
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "115951000119105",
            "display" : "Breast symptom of change in skin"
          }
        ]
      },
      "valueString" : "Keine Hautveränderungen"
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "248819006",
            "display" : "Nipple finding"
          }
        ]
      },
      "valueString" : "Mamille unauffällig, keine Sekretion"
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "301782006",
            "display" : "Finding of lymph node of axillary region"
          }
        ]
      },
      "valueString" : "Axilläre Lymphknoten beidseits unauffällig"
    }
  ]
}