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

• Narrative Content
• JSON

: Fall 10: Therapeutische Mastektomie rechts + SLNB - JSON Representation

Raw json | Download

{
  "resourceType" : "Procedure",
  "id" : "Fall10-Operation-Mastektomie-Rechts",
  "meta" : {
    "profile" : [
      🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-operation"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Procedure Fall10-Operation-Mastektomie-Rechts</b></p><a name=\"Fall10-Operation-Mastektomie-Rechts\"> </a><a name=\"hcFall10-Operation-Mastektomie-Rechts\"> </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-operation.html\">BIH LM Senologie Brustwand-Operation</a></p></div><p><b>MII EX Onko Operation Intention</b>: <span title=\"Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention K}\">kurativ</span></p><p><b>status</b>: Completed</p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 172043006}\">Simple mastectomy</span></p><p><b>code</b>: <span title=\"Codes:{http://fhir.de/CodeSystem/bfarm/ops 5-872}\">Therapeutische Mastektomie rechts</span></p><p><b>subject</b>: <a href=\"Patient-Fall10-Patient-Christina-Becker.html\">Christina Becker  Female, DoB: 1982-12-14 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-010)</a></p><p><b>performed</b>: 2025-06-18</p><p><b>reasonReference</b>: <a href=\"Condition-Fall10-Diagnose-Mammakarzinom.html\">Condition Malignant neoplasm of breast</a></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 73056007}\">Right breast structure</span></p><p><b>outcome</b>: <span title=\"Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus R0}\">R0-Resektion, Sentinel negativ pN0(sn)(0/2), Sofortrekonstruktion mit Implantat</span></p><p><b>followUp</b>: <span title=\"Codes:{http://snomed.info/sct 122462000}\">Redon-Drainage 10 Ch</span>, <span title=\"Codes:{http://snomed.info/sct 182531007}\">Kompressionsverband</span></p></div>"
  },
  "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" : "172043006",
        "display" : "Simple mastectomy"
      }
    ]
  },
  "code" : {
    "coding" : [
      {
        "system" : "http://fhir.de/CodeSystem/bfarm/ops",
        "version" : "2025",
        "code" : "5-872",
        "display" : "(Modifizierte radikale) Mastektomie"
      }
    ],
    "text" : "Therapeutische Mastektomie rechts"
  },
  "subject" : {
    🔗 "reference" : "Patient/Fall10-Patient-Christina-Becker"
  },
  "performedDateTime" : "2025-06-18",
  "reasonReference" : [
    {
      🔗 "reference" : "Condition/Fall10-Diagnose-Mammakarzinom"
    }
  ],
  "bodySite" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "73056007",
          "display" : "Right breast structure"
        }
      ]
    }
  ],
  "outcome" : {
    "coding" : [
      {
        "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus",
        "code" : "R0",
        "display" : "Kein Residualtumor"
      }
    ],
    "text" : "R0-Resektion, Sentinel negativ pN0(sn)(0/2), Sofortrekonstruktion mit Implantat"
  },
  "followUp" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "122462000",
          "display" : "Drainage procedure"
        }
      ],
      "text" : "Redon-Drainage 10 Ch"
    },
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "182531007",
          "display" : "Dressing of wound"
        }
      ],
      "text" : "Kompressionsverband"
    }
  ]
}