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 3: Axilladissektion rechts Level I-II - JSON Representation

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{
  "resourceType" : "Procedure",
  "id" : "Fall3-Operation-Axilladissektion",
  "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 Fall3-Operation-Axilladissektion</b></p><a name=\"Fall3-Operation-Axilladissektion\"> </a><a name=\"hcFall3-Operation-Axilladissektion\"> </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>partOf</b>: <a href=\"Procedure-Fall3-Operation-Mastektomie.html\">Procedure (Modifizierte radikale) Mastektomie</a></p><p><b>status</b>: Completed</p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 234262008}\">Excision of axillary lymph node</span></p><p><b>code</b>: <span title=\"Codes:{http://fhir.de/CodeSystem/bfarm/ops 5-402.11}\">Axilladissektion Level I-II</span></p><p><b>subject</b>: <a href=\"Patient-Fall3-Patient-Sabine-Weber.html\">Sabine Weber  Female, DoB: 1953-07-15 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-003)</a></p><p><b>performed</b>: 2025-04-08</p><p><b>reasonReference</b>: <a href=\"Condition-Fall3-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}\">pN1a (2/12 LK positiv)</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"
          }
        ]
      }
    }
  ],
  "partOf" : [
    {
      🔗 "reference" : "Procedure/Fall3-Operation-Mastektomie"
    }
  ],
  "status" : "completed",
  "category" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "234262008",
        "display" : "Excision of axillary lymph node"
      }
    ]
  },
  "code" : {
    "coding" : [
      {
        "system" : "http://fhir.de/CodeSystem/bfarm/ops",
        "version" : "2025",
        "code" : "5-402.11",
        "display" : "Regionale Lymphadenektomie (Ausräumung mehrerer Lymphknoten einer Region) als selbständiger Eingriff: Axillär: Level 1"
      }
    ],
    "text" : "Axilladissektion Level I-II"
  },
  "subject" : {
    🔗 "reference" : "Patient/Fall3-Patient-Sabine-Weber"
  },
  "performedDateTime" : "2025-04-08",
  "reasonReference" : [
    {
      🔗 "reference" : "Condition/Fall3-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" : "pN1a (2/12 LK positiv)"
  }
}