Kerndatensatz Senologie
0.9.0 - ci-build
Kerndatensatz Senologie - Local Development build (v0.9.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Draft as of 2026-05-04 |
{
"resourceType" : "Questionnaire",
"id" : "senologie-klinische-untersuchung",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire senologie-klinische-untersuchung</b></p><a name=\"senologie-klinische-untersuchung\"> </a><a name=\"hcsenologie-klinische-untersuchung\"> </a><b>Structure</b><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;\"><tr style=\"border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top\"><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Text for the item\">Text</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Cardinality</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The type of the item\">Type</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Additional information about the item\">Description & Constraints</a><span style=\"float: right\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireRoot\" class=\"hierarchy\"/> QuestKlinischeUntersuchung</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">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.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Questionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">https://www.senologie.org/fhir/Questionnaire/senologie-klinische-untersuchung#0.9.0</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.bezugsdiagnose\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-reference.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"reference\" class=\"hierarchy\"/> bezugsdiagnose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Bezugsdiagnose (Seite)</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-reference\">reference</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.untersuchung-datum\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> untersuchung-datum</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Untersuchungsdatum</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Definition: <a href=\"http://hl7.org/fhir/R4/observation.html#Observation.effectiveDateTime\">Observation.effectiveDateTime</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.seitenlokalisation\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> seitenlokalisation</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Untersuchte Seite</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Definition: <a href=\"http://hl7.org/fhir/R4/observation.html#Observation.bodySite\">Observation.bodySite</a><br/>Options: <a href=\"#opt-item.seitenlokalisation\">3 options</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.palpationsbefund\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> palpationsbefund</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Palpationsbefund</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Definition: <a href=\"http://hl7.org/fhir/R4/observation.html#Observation.component.valueString\">Observation.component.valueString</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.hautveraenderungen\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> hautveraenderungen</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Hautveränderungen</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Definition: <a href=\"http://hl7.org/fhir/R4/observation.html#Observation.component.valueString\">Observation.component.valueString</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.mamillenbefund\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> mamillenbefund</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Mamillenbefund (Retraktion, Sekretion, Ekzem)</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Definition: <a href=\"http://hl7.org/fhir/R4/observation.html#Observation.component.valueString\">Observation.component.valueString</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck00.png)\" id=\"item.lymphknotenstatus\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> lymphknotenstatus</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Klinischer Lymphknotenstatus (axillär)</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Definition: <a href=\"http://hl7.org/fhir/R4/observation.html#Observation.component.valueString\">Observation.component.valueString</a></td></tr>\r\n<tr><td colspan=\"5\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table><hr/><p><b>Options Sets</b></p><a name=\"opt-item.seitenlokalisation\"> </a><p><b>Answer options for seitenlokalisation </b></p><ul><li style=\"font-size: 11px\">http://snomed.info/sct#80248007 ("Links")</li><li style=\"font-size: 11px\">http://snomed.info/sct#73056007 ("Rechts")</li><li style=\"font-size: 11px\">http://snomed.info/sct#63762007 ("Beidseits")</li></ul><h2>Contained Resources</h2><hr/><p class=\"res-header-id\"><b>Observation #observation-template</b></p><a name=\"senologie-klinische-untersuchung/observation-template\"> </a><a name=\"hcsenologie-klinische-untersuchung/observation-template\"> </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-klinische-untersuchung.html\">BIH Senologie Klinische Untersuchung</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 32422-8}\">Physical findings of Breast</span></p><p><b>subject</b>: ?rref?</p><p><b>focus</b>: <a href=\"https://simplifier.net/resolve?scope=de.medizininformatikinitiative.kerndatensatz.onkologie@2026.0.3&canonical=http://fhir.org/packages/de.medizininformatikinitiative.kerndatensatz.onkologie/placeholder\">placeholder</a></p><p><b>effective</b>: 2024-01-01</p><p><b>bodySite</b>: <span title=\"Codes:{null null}\"/></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 118242002}\">Finding by palpation</span></p><p><b>value</b>: Palpationsbefund</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 115951000119105}\">Breast symptom of change in skin</span></p><p><b>value</b>: Hautveränderungen</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 248819006}\">Nipple finding</span></p><p><b>value</b>: Mamillenbefund</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 301782006}\">Finding of lymph node of axillary region</span></p><p><b>value</b>: Lymphknotenstatus</p></blockquote></div>"
},
"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
}
]
}