Kerndatensatz Senologie - Local Development build (v0.9.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Questionnaire: Fragebogen: Pathologie Befund (Experimental)
| Official URL: https://www.senologie.org/fhir/Questionnaire/senologie-pathologie | Version: 0.9.0 | |||
| Draft as of 2026-05-04 | Computable Name: QuestPathologieBefund | |||
Fragebogen zur strukturierten Dokumentation des pathologischen Befunds. Nutzt SDC Template-based Extraction mit contained Templates für DiagnosticReport, Specimen, Histologie-Observation und IHC-Observation.
Structure
| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  QuestPathologieBefund | Fragebogen zur strukturierten Dokumentation des pathologischen Befunds. Nutzt SDC Template-based Extraction mit contained Templates für DiagnosticReport, Specimen, Histologie-Observation und IHC-Observation. | Questionnaire | https://www.senologie.org/fhir/Questionnaire/senologie-pathologie#0.9.0 | |
  praeparat | Präparat | 1..1 | group | Value Set: |
   praeparat-art | Art des Präparats | 1..1 | choice | Value Set: Options: 6 options |
 praeparat-entnahmedatum | Entnahmedatum | 1..1 | date | Value Set: |
| praeparat-seite | Seite | 1..1 | choice | Value Set: Options: 2 options |
 praeparat-quadrant | Lokalisation / Quadrant | 0..1 | choice | Value Set: Options: 6 options |
| histologie | Histologie | 0..1 | group | Value Set: |
| histo-typ | Histologischer Typ | 0..1 | choice | Value Set: Options: 4 options |
| histo-grading | Grading (Elston-Ellis) | 0..1 | choice | Value Set: Options: 3 options |
 histo-tumorgroesse | Tumorgröße (mm) | 0..1 | integer | Value Set: |
| histo-invasive-groesse | Invasive Tumorgröße (mm) | 0..1 | integer | Value Set: |
 histo-dcis-anteil | DCIS-Anteil | 0..1 | string | Value Set: |
| histo-resektionsrand | Resektionsrand | 0..1 | choice | Value Set: Options: 3 options |
| histo-sentinel-anzahl | Sentinel-LK untersucht | 0..1 | integer | Value Set: |
| histo-sentinel-befallen | Sentinel-LK befallen | 0..1 | integer | Value Set: |
| ihc | Immunhistochemie / Rezeptorstatus | 0..1 | group | Value Set: |
| ihc-er-prozent | ER Prozent positiv (%) | 0..1 | integer | Value Set: |
| ihc-er-irs | ER IRS Score (0–12) | 0..1 | integer | Value Set: |
| ihc-pr-prozent | PR Prozent positiv (%) | 0..1 | integer | Value Set: |
| ihc-pr-irs | PR IRS Score (0–12) | 0..1 | integer | Value Set: |
| ihc-her2-score | HER2 IHC Score | 0..1 | choice | Value Set: Options: 4 options |
| ihc-her2-fish | HER2 ISH/FISH | 0..1 | choice | Enable When: ihc-her2-score = 2+ Value Set: Options: 3 options |
| ihc-ki67 | Ki-67 Index (%) | 0..1 | integer | Value Set: |
 beurteilung | Gesamtbeurteilung | 0..1 | group | Value Set: |
 beurteilung-ptnm | pTNM | 0..1 | string | Value Set: |
 beurteilung-freitext | Gesamtbeurteilung (Freitext) | 0..1 | text | Value Set: |
| Documentation for this format | ||||
Options Sets
Answer options for praeparat-art
- http://snomed.info/sct#86273004 ("Biopsie")
- http://snomed.info/sct#129300006 ("Punktion")
- http://snomed.info/sct#65801008 ("Exzision")
- http://snomed.info/sct#392021009 ("Brusterhaltende Exzision")
- http://snomed.info/sct#172043006 ("Mastektomie-Präparat")
- Nachresektat
Answer options for praeparat-seite
- http://snomed.info/sct#80248007 ("Links")
- http://snomed.info/sct#73056007 ("Rechts")
Answer options for praeparat-quadrant
- http://snomed.info/sct#76365002 ("Oberer äußerer Quadrant")
- http://snomed.info/sct#77831004 ("Oberer innerer Quadrant")
- http://snomed.info/sct#33564002 ("Unterer äußerer Quadrant")
- http://snomed.info/sct#19100000 ("Unterer innerer Quadrant")
- http://snomed.info/sct#24142002 ("Mamille")
- http://snomed.info/sct#70925003 ("Zentral")
Answer options for histo-typ
- http://snomed.info/sct#82711006 ("Invasives Karzinom NST")
- http://snomed.info/sct#443451005 ("Invasives lobuläres Karzinom")
- http://snomed.info/sct#109889007 ("DCIS")
- Sonstiges
Answer options for histo-grading
- http://snomed.info/sct#54102005 ("G1")
- http://snomed.info/sct#1663004 ("G2")
- http://snomed.info/sct#61026006 ("G3")
Answer options for histo-resektionsrand
- http://snomed.info/sct#258254000 ("R0")
- http://snomed.info/sct#278271003 ("R1")
- http://snomed.info/sct#258253006 ("RX")
Answer options for ihc-her2-score
- 0
- 1+
- 2+
- 3+
Answer options for ihc-her2-fish
- positiv
- negativ
- nicht durchgeführt