Kerndatensatz Senologie
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: Fall 2: Postoperative Komplikation — Serom, Clavien-Dindo I - JSON Representation

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{
  "resourceType" : "Observation",
  "id" : "Fall2-Komplikation-Serom",
  "meta" : {
    "profile" : [
      🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Observation Fall2-Komplikation-Serom</b></p><a name=\"Fall2-Komplikation-Serom\"> </a><a name=\"hcFall2-Komplikation-Serom\"> </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-operative-komplikation.html\">BIH Senologie Operative Komplikation</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 789279006}\">Clavien-Dindo classification grade</span></p><p><b>subject</b>: <a href=\"Patient-Fall2-Patient-Lena-Hoffmann.html\">Lena Hoffmann  Female, DoB: 1980-09-28 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-002)</a></p><p><b>focus</b>: <a href=\"Procedure-Fall2-Operation-Mastektomie.html\">Procedure (Modifizierte radikale) Mastektomie</a></p><p><b>effective</b>: 2025-08-10</p><p><b>value</b>: <span title=\"Codes:{http://snomed.info/sct 1367519000}\">Clavien-Dindo Grad I</span></p><p><b>note</b>: </p><blockquote><div><p>Serom axillär rechts, konservative Behandlung mit Punktion, kein operativer Eingriff erforderlich</p>\n</div></blockquote><p><b>method</b>: <span title=\"Codes:{http://snomed.info/sct 416800000}\">postoperativ, stationär</span></p><h3>Components</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Code</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://snomed.info/sct 116224001}\">Complication of procedure</span></td><td><span title=\"Codes:{http://snomed.info/sct 285345009}\">Serom</span></td></tr></table></div>"
  },
  "status" : "final",
  "code" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "789279006",
        "display" : "Clavien-Dindo classification grade"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/Fall2-Patient-Lena-Hoffmann"
  },
  "focus" : [
    {
      🔗 "reference" : "Procedure/Fall2-Operation-Mastektomie"
    }
  ],
  "effectiveDateTime" : "2025-08-10",
  "valueCodeableConcept" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "1367519000",
        "display" : "Clavien-Dindo classification grade I"
      }
    ],
    "text" : "Clavien-Dindo Grad I"
  },
  "note" : [
    {
      "text" : "Serom axillär rechts, konservative Behandlung mit Punktion, kein operativer Eingriff erforderlich"
    }
  ],
  "method" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "416800000",
        "display" : "Inpatient"
      }
    ],
    "text" : "postoperativ, stationär"
  },
  "component" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "116224001",
            "display" : "Complication of procedure"
          }
        ]
      },
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "285345009",
            "display" : "Seroma"
          }
        ],
        "text" : "Serom"
      }
    }
  ]
}