{ "resourceType" : "Questionnaire", "id" : "senologie-bildgebung", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Questionnaire senologie-bildgebung

Structure\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" QuestBildgebungFragebogen zur strukturierten Dokumentation der Bildgebung Mamma (Mammographie, Sonographie, MRT, Tomosynthese). Nutzt SDC Template-based Extraction mit contained Templates für DiagnosticReport, Observation und BodyStructure.Questionnairehttps://www.senologie.org/fhir/Questionnaire/senologie-bildgebung#0.9.0
\".\"\".\"\".\" untersuchungUntersuchung1..1group
\".\"\".\"\".\"\".\" untersuchung-datumUntersuchungsdatum1..1date
\".\"\".\"\".\"\".\" bildgebungsartBildgebungsart1..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" befundender-arztBefundender Arzt0..1string
\".\"\".\"\".\" lokalisationTumorlokalisation0..1group
\".\"\".\"\".\"\".\" lokalisation-seiteSeite1..1choiceOptions: 3 options
\".\"\".\"\".\"\".\" lokalisation-quadrantQuadrant0..1choiceOptions: 6 options
\".\"\".\"\".\"\".\" lokalisation-uhrzeitUhrzeitposition0..1choiceOptions: 12 options
\".\"\".\"\".\"\".\" lokalisation-mamillenabstandAbstand von Mamille (mm)0..1integer
\".\"\".\"\".\" befundBefund0..1group
\".\"\".\"\".\"\".\" birads-kategorieBI-RADS Kategorie0..1choiceOptions: 7 options
\".\"\".\"\".\"\".\" acr-brustdichteACR Brustdichte0..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" herdbefund-groesseHerdbefund Größe (mm)0..1integer
\".\"\".\"\".\"\".\" herdbefund-beschreibungHerdbefund Beschreibung0..1text
\".\"\".\"\".\"\".\" mikrokalkMikrokalkifikationen0..1boolean
\".\"\".\"\".\"\".\" mikrokalk-beschreibungMikrokalkifikationen Beschreibung0..1textEnable When: mikrokalk = true
\".\"\".\"\".\"\".\" lymphknoten-auffaelligAxilläre Lymphknoten auffällig0..1boolean
\".\"\".\"\".\" zusammenfassungZusammenfassung0..1group
\".\"\".\"\".\"\".\" gesamtbeurteilungGesamtbeurteilung0..1text
\".\"\".\"\".\"\".\" empfehlungEmpfehlung0..1text

\"doco\" Documentation for this format

Options Sets

Answer options for bildgebungsart

Answer options for lokalisation-seite

Answer options for lokalisation-quadrant

Answer options for lokalisation-uhrzeit

Answer options for birads-kategorie

Answer options for acr-brustdichte

Contained Resources

DiagnosticReport #bildgebung-report-template

Breast Screening (Radiology)

SubjectUnable to get Patient Details

Report Details

Observation #bildgebung-befund-template

status: Final

code: Breast Imaging-Reporting and Data System

subject: ?rref?

BodyStructure #bildgebung-bodystructure-template

active: true

patient: ?rref?

" }, "contained" : [{ "resourceType" : "DiagnosticReport", "id" : "bildgebung-report-template", "status" : "final", "category" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0074", "code" : "RAD", "display" : "Radiology" }] }], "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "24606-6", "display" : "Breast Screening" }] }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "Observation", "id" : "bildgebung-befund-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "72018-2", "display" : "Breast Imaging-Reporting and Data System" }] }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "BodyStructure", "id" : "bildgebung-bodystructure-template", "active" : true, "patient" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }], "extension" : [{ "extension" : [{ "url" : "name", "valueCoding" : { "system" : "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext", "code" : "patient" } }, { "url" : "type", "valueCode" : "Patient" }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext" }], "url" : "https://www.senologie.org/fhir/Questionnaire/senologie-bildgebung", "version" : "0.9.0", "name" : "QuestBildgebung", "title" : "Fragebogen: Bildgebung Mamma", "status" : "draft", "experimental" : true, "subjectType" : ["Patient"], "date" : "2026-05-04T16:55:55+00:00", "publisher" : "Berlin Institute of Health at Charité (BIH)", "contact" : [{ "name" : "Berlin Institute of Health at Charité (BIH)", "telecom" : [{ "system" : "url", "value" : "https://www.bihealth.org" }] }], "description" : "Fragebogen zur strukturierten Dokumentation der Bildgebung Mamma (Mammographie, Sonographie, MRT, Tomosynthese). Nutzt SDC Template-based Extraction mit contained Templates für DiagnosticReport, Observation und BodyStructure.", "item" : [{ "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#bildgebung-report-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "untersuchung", "text" : "Untersuchung", "type" : "group", "required" : true, "item" : [{ "linkId" : "untersuchung-datum", "text" : "Untersuchungsdatum", "type" : "date", "required" : true }, { "linkId" : "bildgebungsart", "text" : "Bildgebungsart", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://loinc.org", "code" : "24606-6", "display" : "Mammographie" } }, { "valueCoding" : { "system" : "http://loinc.org", "code" : "24590-2", "display" : "Sonographie" } }, { "valueCoding" : { "system" : "http://loinc.org", "code" : "24589-4", "display" : "MRT Mamma" } }, { "valueString" : "Tomosynthese" }] }, { "linkId" : "befundender-arzt", "text" : "Befundender Arzt", "type" : "string", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#bildgebung-bodystructure-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "lokalisation", "text" : "Tumorlokalisation", "type" : "group", "required" : false, "item" : [{ "linkId" : "lokalisation-seite", "text" : "Seite", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "80248007", "display" : "Links" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "73056007", "display" : "Rechts" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "63762007", "display" : "Beidseits" } }] }, { "linkId" : "lokalisation-quadrant", "text" : "Quadrant", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "76365002", "display" : "Oberer äußerer Quadrant" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "77831004", "display" : "Oberer innerer Quadrant" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "33564002", "display" : "Unterer äußerer Quadrant" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "19100000", "display" : "Unterer innerer Quadrant" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "24142002", "display" : "Mamille" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "70925003", "display" : "Zentral" } }] }, { "linkId" : "lokalisation-uhrzeit", "text" : "Uhrzeitposition", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "12 Uhr" }, { "valueString" : "1 Uhr" }, { "valueString" : "2 Uhr" }, { "valueString" : "3 Uhr" }, { "valueString" : "4 Uhr" }, { "valueString" : "5 Uhr" }, { "valueString" : "6 Uhr" }, { "valueString" : "7 Uhr" }, { "valueString" : "8 Uhr" }, { "valueString" : "9 Uhr" }, { "valueString" : "10 Uhr" }, { "valueString" : "11 Uhr" }] }, { "linkId" : "lokalisation-mamillenabstand", "text" : "Abstand von Mamille (mm)", "type" : "integer", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#bildgebung-befund-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "befund", "text" : "Befund", "type" : "group", "required" : false, "item" : [{ "linkId" : "birads-kategorie", "code" : [{ "system" : "http://loinc.org", "code" : "72018-2", "display" : "BI-RADS" }], "text" : "BI-RADS Kategorie", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "397138000", "display" : "BI-RADS 0 — Zusätzliche Bildgebung erforderlich" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "397140005", "display" : "BI-RADS 1 — Unauffällig" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "397141009", "display" : "BI-RADS 2 — Gutartiger Befund" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "397143007", "display" : "BI-RADS 3 — Wahrscheinlich gutartig" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "397144001", "display" : "BI-RADS 4 — Suspekt" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "397145000", "display" : "BI-RADS 5 — Hochverdächtig auf Malignität" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "6111000179101", "display" : "BI-RADS 6 — Histologisch gesichert maligne" } }] }, { "linkId" : "acr-brustdichte", "code" : [{ "system" : "http://loinc.org", "code" : "89180-4", "display" : "Breast density" }], "text" : "ACR Brustdichte", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "A — Fast vollständig fetthaltig" }, { "valueString" : "B — Verstreute fibroglanduläre Verdichtungen" }, { "valueString" : "C — Heterogen dicht" }, { "valueString" : "D — Extrem dicht" }] }, { "linkId" : "herdbefund-groesse", "text" : "Herdbefund Größe (mm)", "type" : "integer", "required" : false }, { "linkId" : "herdbefund-beschreibung", "text" : "Herdbefund Beschreibung", "type" : "text", "required" : false }, { "linkId" : "mikrokalk", "text" : "Mikrokalkifikationen", "type" : "boolean", "required" : false }, { "linkId" : "mikrokalk-beschreibung", "text" : "Mikrokalkifikationen Beschreibung", "type" : "text", "enableWhen" : [{ "question" : "mikrokalk", "operator" : "=", "answerBoolean" : true }], "required" : false }, { "linkId" : "lymphknoten-auffaellig", "text" : "Axilläre Lymphknoten auffällig", "type" : "boolean", "required" : false }] }, { "linkId" : "zusammenfassung", "text" : "Zusammenfassung", "type" : "group", "required" : false, "item" : [{ "linkId" : "gesamtbeurteilung", "text" : "Gesamtbeurteilung", "type" : "text", "required" : false }, { "linkId" : "empfehlung", "text" : "Empfehlung", "type" : "text", "required" : false }] }] }