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

Generated Narrative: Questionnaire senologie-klinische-untersuchung

Structure\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" QuestKlinischeUntersuchungFragebogen zur strukturierten Dokumentation der klinischen Brustuntersuchung. Nutzt SDC Template-based Extraction mit dem Senologie_Klinische_Untersuchung-Profil (Observation) als Ziel. Das Extraction-Template liegt unter input/resources/Questionnaire-senologie-klinische-untersuchung-template.json.Questionnairehttps://www.senologie.org/fhir/Questionnaire/senologie-klinische-untersuchung#0.9.0
\".\"\".\"\".\" bezugsdiagnoseBezugsdiagnose (Seite)1..1reference
\".\"\".\"\".\" untersuchung-datumUntersuchungsdatum1..1dateDefinition: Observation.effectiveDateTime
\".\"\".\"\".\" seitenlokalisationUntersuchte Seite1..1choiceDefinition: Observation.bodySite
Options: 3 options
\".\"\".\"\".\" palpationsbefundPalpationsbefund0..1textDefinition: Observation.component.valueString
\".\"\".\"\".\" hautveraenderungenHautveränderungen0..1textDefinition: Observation.component.valueString
\".\"\".\"\".\" mamillenbefundMamillenbefund (Retraktion, Sekretion, Ekzem)0..1textDefinition: Observation.component.valueString
\".\"\".\"\".\" lymphknotenstatusKlinischer Lymphknotenstatus (axillär)0..1textDefinition: Observation.component.valueString

\"doco\" Documentation for this format

Options Sets

Answer options for seitenlokalisation

Contained Resources

Observation #observation-template

Profile: BIH Senologie Klinische Untersuchung

status: Final

code: Physical findings of Breast

subject: ?rref?

focus: placeholder

effective: 2024-01-01

bodySite:

component

code: Finding by palpation

value: Palpationsbefund

component

code: Breast symptom of change in skin

value: Hautveränderungen

component

code: Nipple finding

value: Mamillenbefund

component

code: Finding of lymph node of axillary region

value: Lymphknotenstatus

" }, "contained" : [{ "resourceType" : "Observation", "id" : "observation-template", "meta" : { "profile" : ["https://www.senologie.org/fhir/StructureDefinition/senologie-klinische-untersuchung"] }, "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "32422-8", "display" : "Physical findings of Breast" }] }, "subject" : { "_reference" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "'Patient/' + %patient.id" }] } }, "focus" : [{ "reference" : "placeholder", "_reference" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='bezugsdiagnose').answer.valueReference.reference" }] } }], "effectiveDateTime" : "2024-01-01", "_effectiveDateTime" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='untersuchung-datum').answer.valueDate" }] }, "bodySite" : { "coding" : [{ "_system" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='seitenlokalisation').answer.valueCoding.system" }] }, "_code" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='seitenlokalisation').answer.valueCoding.code" }] }, "_display" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='seitenlokalisation').answer.valueCoding.display" }] } }] }, "component" : [{ "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "118242002", "display" : "Finding by palpation" }] }, "valueString" : "Palpationsbefund", "_valueString" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='palpationsbefund').answer.valueString" }] } }, { "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "115951000119105", "display" : "Breast symptom of change in skin" }] }, "valueString" : "Hautveränderungen", "_valueString" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='hautveraenderungen').answer.valueString" }] } }, { "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "248819006", "display" : "Nipple finding" }] }, "valueString" : "Mamillenbefund", "_valueString" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='mamillenbefund').answer.valueString" }] } }, { "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "301782006", "display" : "Finding of lymph node of axillary region" }] }, "valueString" : "Lymphknotenstatus", "_valueString" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='lymphknotenstatus').answer.valueString" }] } }] }], "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" }, { "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#observation-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "url" : "https://www.senologie.org/fhir/Questionnaire/senologie-klinische-untersuchung", "version" : "0.9.0", "name" : "QuestKlinischeUntersuchung", "title" : "Fragebogen: Klinische Untersuchung 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 klinischen Brustuntersuchung. Nutzt SDC Template-based Extraction mit dem Senologie_Klinische_Untersuchung-Profil (Observation) als Ziel. Das Extraction-Template liegt unter input/resources/Questionnaire-senologie-klinische-untersuchung-template.json.", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-candidateExpression", "valueExpression" : { "language" : "application/x-fhir-query", "expression" : "Condition?patient={{%patient.id}}&code=254837009&clinical-status=active" } }, { "extension" : [{ "url" : "path", "valueString" : "code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm').first().code" }, { "url" : "label", "valueString" : "ICD-10" }, { "url" : "forDisplay", "valueBoolean" : false }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-choiceColumn" }, { "extension" : [{ "url" : "path", "valueString" : "bodySite.coding.first().display" }, { "url" : "label", "valueString" : "Seite" }, { "url" : "forDisplay", "valueBoolean" : true }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-choiceColumn" }], "linkId" : "bezugsdiagnose", "text" : "Bezugsdiagnose (Seite)", "type" : "reference", "required" : true }, { "linkId" : "untersuchung-datum", "definition" : "http://hl7.org/fhir/StructureDefinition/Observation#Observation.effectiveDateTime", "text" : "Untersuchungsdatum", "type" : "date", "required" : true }, { "linkId" : "seitenlokalisation", "definition" : "http://hl7.org/fhir/StructureDefinition/Observation#Observation.bodySite", "text" : "Untersuchte 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" : "palpationsbefund", "definition" : "http://hl7.org/fhir/StructureDefinition/Observation#Observation.component.valueString", "code" : [{ "system" : "http://snomed.info/sct", "code" : "118242002", "display" : "Finding by palpation" }], "text" : "Palpationsbefund", "type" : "text", "required" : false }, { "linkId" : "hautveraenderungen", "definition" : "http://hl7.org/fhir/StructureDefinition/Observation#Observation.component.valueString", "code" : [{ "system" : "http://snomed.info/sct", "code" : "115951000119105", "display" : "Breast symptom of change in skin" }], "text" : "Hautveränderungen", "type" : "text", "required" : false }, { "linkId" : "mamillenbefund", "definition" : "http://hl7.org/fhir/StructureDefinition/Observation#Observation.component.valueString", "code" : [{ "system" : "http://snomed.info/sct", "code" : "248819006", "display" : "Nipple finding" }], "text" : "Mamillenbefund (Retraktion, Sekretion, Ekzem)", "type" : "text", "required" : false }, { "linkId" : "lymphknotenstatus", "definition" : "http://hl7.org/fhir/StructureDefinition/Observation#Observation.component.valueString", "code" : [{ "system" : "http://snomed.info/sct", "code" : "284429001", "display" : "Examination of axillary lymph nodes" }], "text" : "Klinischer Lymphknotenstatus (axillär)", "type" : "text", "required" : false }] }