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

Generated Narrative: Questionnaire senologie-pathologie

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\r\n\r\n\r\n
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" QuestPathologieBefundFragebogen zur strukturierten Dokumentation des pathologischen Befunds. Nutzt SDC Template-based Extraction mit contained Templates für DiagnosticReport, Specimen, Histologie-Observation und IHC-Observation.Questionnairehttps://www.senologie.org/fhir/Questionnaire/senologie-pathologie#0.9.0
\".\"\".\"\".\" praeparatPräparat1..1group
\".\"\".\"\".\"\".\" praeparat-artArt des Präparats1..1choiceOptions: 6 options
\".\"\".\"\".\"\".\" praeparat-entnahmedatumEntnahmedatum1..1date
\".\"\".\"\".\"\".\" praeparat-seiteSeite1..1choiceOptions: 2 options
\".\"\".\"\".\"\".\" praeparat-quadrantLokalisation / Quadrant0..1choiceOptions: 6 options
\".\"\".\"\".\" histologieHistologie0..1group
\".\"\".\"\".\"\".\" histo-typHistologischer Typ0..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" histo-gradingGrading (Elston-Ellis)0..1choiceOptions: 3 options
\".\"\".\"\".\"\".\" histo-tumorgroesseTumorgröße (mm)0..1integer
\".\"\".\"\".\"\".\" histo-invasive-groesseInvasive Tumorgröße (mm)0..1integer
\".\"\".\"\".\"\".\" histo-dcis-anteilDCIS-Anteil0..1string
\".\"\".\"\".\"\".\" histo-resektionsrandResektionsrand0..1choiceOptions: 3 options
\".\"\".\"\".\"\".\" histo-sentinel-anzahlSentinel-LK untersucht0..1integer
\".\"\".\"\".\"\".\" histo-sentinel-befallenSentinel-LK befallen0..1integer
\".\"\".\"\".\" ihcImmunhistochemie / Rezeptorstatus0..1group
\".\"\".\"\".\"\".\" ihc-er-prozentER Prozent positiv (%)0..1integer
\".\"\".\"\".\"\".\" ihc-er-irsER IRS Score (0–12)0..1integer
\".\"\".\"\".\"\".\" ihc-pr-prozentPR Prozent positiv (%)0..1integer
\".\"\".\"\".\"\".\" ihc-pr-irsPR IRS Score (0–12)0..1integer
\".\"\".\"\".\"\".\" ihc-her2-scoreHER2 IHC Score0..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" ihc-her2-fishHER2 ISH/FISH0..1choiceEnable When: ihc-her2-score = 2+
Options: 3 options
\".\"\".\"\".\"\".\" ihc-ki67Ki-67 Index (%)0..1integer
\".\"\".\"\".\" beurteilungGesamtbeurteilung0..1group
\".\"\".\"\".\"\".\" beurteilung-ptnmpTNM0..1string
\".\"\".\"\".\"\".\" beurteilung-freitextGesamtbeurteilung (Freitext)0..1text

\"doco\" Documentation for this format

Options Sets

Answer options for praeparat-art

Answer options for praeparat-seite

Answer options for praeparat-quadrant

Answer options for histo-typ

Answer options for histo-grading

Answer options for histo-resektionsrand

Answer options for ihc-her2-score

Answer options for ihc-her2-fish

Contained Resources

DiagnosticReport #patho-report-template

Pathology synoptic report (Surgical Pathology)

SubjectUnable to get Patient Details

Report Details

Specimen #patho-specimen-template

status: Available

subject: ?rref?

Observation #patho-histo-template

status: Final

code: Histology type in Cancer specimen

subject: ?rref?

Observation #patho-ihc-template

status: Final

code: Immunhistochemie / Rezeptorstatus

subject: ?rref?

" }, "contained" : [{ "resourceType" : "DiagnosticReport", "id" : "patho-report-template", "status" : "final", "category" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0074", "code" : "SP", "display" : "Surgical Pathology" }] }], "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "60568-3", "display" : "Pathology synoptic report" }] }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "Specimen", "id" : "patho-specimen-template", "status" : "available", "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "Observation", "id" : "patho-histo-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "33731-1", "display" : "Histology type in Cancer specimen" }] }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "Observation", "id" : "patho-ihc-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "85337-4", "display" : "Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain" }], "text" : "Immunhistochemie / Rezeptorstatus" }, "subject" : { "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-pathologie", "version" : "0.9.0", "name" : "QuestPathologieBefund", "title" : "Fragebogen: Pathologie Befund", "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 des pathologischen Befunds. Nutzt SDC Template-based Extraction mit contained Templates für DiagnosticReport, Specimen, Histologie-Observation und IHC-Observation.", "item" : [{ "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#patho-specimen-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "praeparat", "text" : "Präparat", "type" : "group", "required" : true, "item" : [{ "linkId" : "praeparat-art", "text" : "Art des Präparats", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "86273004", "display" : "Biopsie" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "129300006", "display" : "Punktion" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "65801008", "display" : "Exzision" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "392021009", "display" : "Brusterhaltende Exzision" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "172043006", "display" : "Mastektomie-Präparat" } }, { "valueString" : "Nachresektat" }] }, { "linkId" : "praeparat-entnahmedatum", "text" : "Entnahmedatum", "type" : "date", "required" : true }, { "linkId" : "praeparat-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" } }] }, { "linkId" : "praeparat-quadrant", "text" : "Lokalisation / 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" } }] }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#patho-histo-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "histologie", "text" : "Histologie", "type" : "group", "required" : false, "item" : [{ "linkId" : "histo-typ", "text" : "Histologischer Typ", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "82711006", "display" : "Invasives Karzinom NST" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "443451005", "display" : "Invasives lobuläres Karzinom" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "109889007", "display" : "DCIS" } }, { "valueString" : "Sonstiges" }] }, { "linkId" : "histo-grading", "code" : [{ "system" : "http://snomed.info/sct", "code" : "371469007", "display" : "Histologic grade" }], "text" : "Grading (Elston-Ellis)", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "54102005", "display" : "G1" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1663004", "display" : "G2" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "61026006", "display" : "G3" } }] }, { "linkId" : "histo-tumorgroesse", "code" : [{ "system" : "http://loinc.org", "code" : "21889-1", "display" : "Size Tumor" }], "text" : "Tumorgröße (mm)", "type" : "integer", "required" : false }, { "linkId" : "histo-invasive-groesse", "code" : [{ "system" : "http://loinc.org", "code" : "33728-7", "display" : "Size.maximum dimension in Tumor" }], "text" : "Invasive Tumorgröße (mm)", "type" : "integer", "required" : false }, { "linkId" : "histo-dcis-anteil", "text" : "DCIS-Anteil", "type" : "string", "required" : false }, { "linkId" : "histo-resektionsrand", "code" : [{ "system" : "http://snomed.info/sct", "code" : "395536008", "display" : "Surgical margin finding" }], "text" : "Resektionsrand", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "258254000", "display" : "R0" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "278271003", "display" : "R1" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "258253006", "display" : "RX" } }] }, { "linkId" : "histo-sentinel-anzahl", "code" : [{ "system" : "http://loinc.org", "code" : "85347-3", "display" : "Sentinel lymph nodes examined [#]" }], "text" : "Sentinel-LK untersucht", "type" : "integer", "required" : false }, { "linkId" : "histo-sentinel-befallen", "code" : [{ "system" : "http://loinc.org", "code" : "92832-5", "display" : "Sentinel lymph nodes with metastasis [#]" }], "text" : "Sentinel-LK befallen", "type" : "integer", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#patho-ihc-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "ihc", "text" : "Immunhistochemie / Rezeptorstatus", "type" : "group", "required" : false, "item" : [{ "linkId" : "ihc-er-prozent", "code" : [{ "system" : "http://loinc.org", "code" : "85337-4", "display" : "Estrogen receptor" }], "text" : "ER Prozent positiv (%)", "type" : "integer", "required" : false }, { "linkId" : "ihc-er-irs", "text" : "ER IRS Score (0–12)", "type" : "integer", "required" : false }, { "linkId" : "ihc-pr-prozent", "code" : [{ "system" : "http://loinc.org", "code" : "85339-0", "display" : "Progesterone receptor" }], "text" : "PR Prozent positiv (%)", "type" : "integer", "required" : false }, { "linkId" : "ihc-pr-irs", "text" : "PR IRS Score (0–12)", "type" : "integer", "required" : false }, { "linkId" : "ihc-her2-score", "code" : [{ "system" : "http://loinc.org", "code" : "85319-2", "display" : "HER2 [Presence] in Breast cancer specimen" }], "text" : "HER2 IHC Score", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "0" }, { "valueString" : "1+" }, { "valueString" : "2+" }, { "valueString" : "3+" }] }, { "linkId" : "ihc-her2-fish", "code" : [{ "system" : "http://loinc.org", "code" : "85318-4", "display" : "ERBB2 gene duplication" }], "text" : "HER2 ISH/FISH", "type" : "choice", "enableWhen" : [{ "question" : "ihc-her2-score", "operator" : "=", "answerString" : "2+" }], "required" : false, "answerOption" : [{ "valueString" : "positiv" }, { "valueString" : "negativ" }, { "valueString" : "nicht durchgeführt" }] }, { "linkId" : "ihc-ki67", "code" : [{ "system" : "http://loinc.org", "code" : "29593-1", "display" : "Ki-67 [Percentile] in Tissue" }], "text" : "Ki-67 Index (%)", "type" : "integer", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#patho-report-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "beurteilung", "text" : "Gesamtbeurteilung", "type" : "group", "required" : false, "item" : [{ "linkId" : "beurteilung-ptnm", "text" : "pTNM", "type" : "string", "required" : false }, { "linkId" : "beurteilung-freitext", "text" : "Gesamtbeurteilung (Freitext)", "type" : "text", "required" : false }] }] }