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

Generated Narrative: Questionnaire senologie-erstanamnese

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\r\n\r\n
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" QuestErstanamneseFragebogen zur Erstanamnese mit Allgemeiner Anamnese, Gynäkologischer Anamnese, Raucherstatus und Familienanamnese. Nutzt SDC Template-based Extraction.Questionnairehttps://www.senologie.org/fhir/Questionnaire/senologie-erstanamnese#0.9.0
\".\"\".\"\".\" allgemeine-anamneseAllgemeine Anamnese1..1group
\".\"\".\"\".\"\".\" datum-vorstellungDatum der Vorstellung1..1date
\".\"\".\"\".\"\".\" vorstellungsgrundVorstellungsgrund1..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" screeningstatusScreeningstatus0..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" groesseKörpergröße (cm)0..1integer
\".\"\".\"\".\"\".\" gewichtKörpergewicht (kg)0..1integer
\".\"\".\"\".\"\".\" ecogECOG Leistungsstatus0..1choiceOptions: 5 options
\".\"\".\"\".\" raucherstatusRaucherstatus0..1group
\".\"\".\"\".\"\".\" raucherstatus-wertRaucherstatus0..1choiceOptions: 3 options
\".\"\".\"\".\" gynaekologische-anamneseGynäkologische Anamnese0..1group
\".\"\".\"\".\"\".\" menarchealterMenarchealter (Jahre)0..1integer
\".\"\".\"\".\"\".\" menopausenstatusMenopausenstatus0..1choiceOptions: 3 options
\".\"\".\"\".\"\".\" gravidaGravida (Schwangerschaften)0..1integer
\".\"\".\"\".\"\".\" paraPara (Geburten)0..1integer
\".\"\".\"\".\"\".\" hormonersatztherapieHormonersatztherapie (HRT)0..1choiceOptions: 2 options
\".\"\".\"\".\"\".\" orale-kontrazeptionHormonelle Verhütung0..1choiceOptions: 3 options
\".\"\".\"\".\"\".\" stilldauerStilldauer (Monate)0..1integer
\".\"\".\"\".\" familienanamneseFamilienanamnese0..1group
\".\"\".\"\".\"\".\" familienmitgliedFamilienmitglied0..*group
\".\"\".\"\".\"\".\"\".\" verwandtschaftsgradVerwandtschaftsgrad1..1choiceOptions: 5 options
\".\"\".\"\".\"\".\"\".\" erkrankungErkrankung1..1choiceOptions: 3 options
\".\"\".\"\".\"\".\"\".\" erkrankungsalterErkrankungsalter (Jahre)0..1integer

\"doco\" Documentation for this format

Options Sets

Answer options for vorstellungsgrund

Answer options for screeningstatus

Answer options for ecog

Answer options for raucherstatus-wert

Answer options for menopausenstatus

Answer options for hormonersatztherapie

Answer options for orale-kontrazeption

Answer options for verwandtschaftsgrad

Answer options for erkrankung

Contained Resources

Observation #anamnese-gynaek-template

status: Final

code: Gynäkologische Anamnese

subject: ?rref?

Observation #anamnese-raucher-template

status: Final

code: Tobacco smoking status

subject: ?rref?

FamilyMemberHistory #anamnese-familie-template

status: Completed

patient: ?rref?

relationship: family member

" }, "contained" : [{ "resourceType" : "Observation", "id" : "anamnese-gynaek-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "89221-6", "display" : "Gynecology History and physical note" }], "text" : "Gynäkologische Anamnese" }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "Observation", "id" : "anamnese-raucher-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "72166-2", "display" : "Tobacco smoking status" }, { "system" : "http://snomed.info/sct", "code" : "77176002", "display" : "Smoker" }] }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "FamilyMemberHistory", "id" : "anamnese-familie-template", "status" : "completed", "patient" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] }, "relationship" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode", "code" : "FAMMEMB", "display" : "family member" }] } }], "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-erstanamnese", "version" : "0.9.0", "name" : "QuestErstanamnese", "title" : "Fragebogen: Erstanamnese", "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 Erstanamnese mit Allgemeiner Anamnese, Gynäkologischer Anamnese, Raucherstatus und Familienanamnese. Nutzt SDC Template-based Extraction.", "item" : [{ "linkId" : "allgemeine-anamnese", "text" : "Allgemeine Anamnese", "type" : "group", "required" : true, "item" : [{ "linkId" : "datum-vorstellung", "text" : "Datum der Vorstellung", "type" : "date", "required" : true }, { "linkId" : "vorstellungsgrund", "text" : "Vorstellungsgrund", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "185387006", "display" : "Erstvorstellung" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "726007", "display" : "Zweitmeinung" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "390906007", "display" : "Nachsorge" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "183620003", "display" : "Wiedervorstellung" } }] }, { "linkId" : "screeningstatus", "text" : "Screeningstatus", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "268547008", "display" : "Screening-detektiert" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "444589003", "display" : "Intervallkarzinom" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "129434009", "display" : "Selbstuntersuchung" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "261087003", "display" : "Zufallsbefund" } }] }, { "linkId" : "groesse", "code" : [{ "system" : "http://loinc.org", "code" : "8302-2", "display" : "Body height" }], "text" : "Körpergröße (cm)", "type" : "integer", "required" : false }, { "linkId" : "gewicht", "code" : [{ "system" : "http://loinc.org", "code" : "29463-7", "display" : "Body weight" }], "text" : "Körpergewicht (kg)", "type" : "integer", "required" : false }, { "linkId" : "ecog", "code" : [{ "system" : "http://loinc.org", "code" : "89247-1", "display" : "ECOG Performance Status" }], "text" : "ECOG Leistungsstatus", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "0 — Normale Aktivität" }, { "valueString" : "1 — Einschränkung bei Anstrengung" }, { "valueString" : "2 — Gehfähig, nicht arbeitsfähig" }, { "valueString" : "3 — Begrenzte Selbstversorgung" }, { "valueString" : "4 — Völlig pflegebedürftig" }] }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#anamnese-raucher-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "raucherstatus", "text" : "Raucherstatus", "type" : "group", "required" : false, "item" : [{ "linkId" : "raucherstatus-wert", "text" : "Raucherstatus", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://loinc.org", "code" : "LA18978-9", "display" : "Nie geraucht" } }, { "valueCoding" : { "system" : "http://loinc.org", "code" : "LA15920-4", "display" : "Ehemaliger Raucher" } }, { "valueCoding" : { "system" : "http://loinc.org", "code" : "LA18976-3", "display" : "Aktueller Raucher" } }] }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#anamnese-gynaek-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "gynaekologische-anamnese", "text" : "Gynäkologische Anamnese", "type" : "group", "required" : false, "item" : [{ "linkId" : "menarchealter", "code" : [{ "system" : "http://loinc.org", "code" : "42798-9", "display" : "Age at menarche" }], "text" : "Menarchealter (Jahre)", "type" : "integer", "required" : false }, { "linkId" : "menopausenstatus", "text" : "Menopausenstatus", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "309606002", "display" : "Prämenopausal" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "161541000119104", "display" : "Perimenopausal" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "76498008", "display" : "Postmenopausal" } }] }, { "linkId" : "gravida", "code" : [{ "system" : "http://loinc.org", "code" : "11996-6", "display" : "Pregnancies" }], "text" : "Gravida (Schwangerschaften)", "type" : "integer", "required" : false }, { "linkId" : "para", "code" : [{ "system" : "http://loinc.org", "code" : "11977-6", "display" : "Parity" }], "text" : "Para (Geburten)", "type" : "integer", "required" : false }, { "linkId" : "hormonersatztherapie", "code" : [{ "system" : "http://snomed.info/sct", "code" : "266717002", "display" : "Hormone replacement therapy" }], "text" : "Hormonersatztherapie (HRT)", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "373066001", "display" : "Ja" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "373067005", "display" : "Nein" } }] }, { "linkId" : "orale-kontrazeption", "text" : "Hormonelle Verhütung", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "Nie" }, { "valueString" : "Früher" }, { "valueString" : "Aktuell" }] }, { "linkId" : "stilldauer", "text" : "Stilldauer (Monate)", "type" : "integer", "required" : false }] }, { "linkId" : "familienanamnese", "text" : "Familienanamnese", "type" : "group", "required" : false, "item" : [{ "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#anamnese-familie-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "familienmitglied", "text" : "Familienmitglied", "type" : "group", "required" : false, "repeats" : true, "item" : [{ "linkId" : "verwandtschaftsgrad", "text" : "Verwandtschaftsgrad", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode", "code" : "MTH", "display" : "Mutter" } }, { "valueCoding" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode", "code" : "SIS", "display" : "Schwester" } }, { "valueCoding" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode", "code" : "DAUC", "display" : "Tochter" } }, { "valueCoding" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode", "code" : "GRMTH", "display" : "Großmutter" } }, { "valueCoding" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode", "code" : "AUNT", "display" : "Tante" } }] }, { "linkId" : "erkrankung", "text" : "Erkrankung", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "254837009", "display" : "Mammakarzinom" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "363443007", "display" : "Ovarialkarzinom" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "74964007", "display" : "Sonstiges" } }] }, { "linkId" : "erkrankungsalter", "text" : "Erkrankungsalter (Jahre)", "type" : "integer", "required" : false }] }] }] }