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: Postoperative Dokumentation (Experimental)
| Official URL: https://www.senologie.org/fhir/Questionnaire/senologie-postop | Version: 0.9.0 | |||
| Draft as of 2026-05-04 | Computable Name: QuestPostOPDokumentation | |||
Fragebogen zur postoperativen Dokumentation (Operative Therapie, Komplikationen, Postoperative Anordnungen/Follow-up). Nutzt SDC Template-based Extraction mit zwei contained Templates: Procedure (Senologie_Operation) und Observation (Senologie_Operative_Komplikation).
Structure
| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  QuestPostOPDokumentation | Fragebogen zur postoperativen Dokumentation (Operative Therapie, Komplikationen, Postoperative Anordnungen/Follow-up). Nutzt SDC Template-based Extraction mit zwei contained Templates: Procedure (Senologie_Operation) und Observation (Senologie_Operative_Komplikation). | Questionnaire | https://www.senologie.org/fhir/Questionnaire/senologie-postop#0.9.0 | |
  bezugsdiagnose | Bezugsdiagnose (Seite) | 1..1 | reference | Value Set: |
  operation | Operative Therapie | 1..1 | group | Value Set: |
  op-kategorie | Art der Operation | 1..1 | choice | Definition: Procedure.category Value Set: BIH LM Senologie Operation |
| op-seite | Seite | 1..1 | choice | Definition: Procedure.bodySite Value Set: Options: 3 options |
 op-datum | OP-Datum | 1..1 | date | Definition: Procedure.performedDateTime Value Set: |
 op-code-text | Beschreibung der OP (Freitext, z.B. "BET links, Sentinel-LK-Biopsie") | 0..1 | string | Definition: Procedure.code.text Value Set: |
| op-intention | OP-Intention | 0..1 | choice | Definition: Procedure.extension:Intention.valueCodeableConcept Value Set: Options: 6 options |
| op-outcome | OP-Outcome (z.B. R-Status, Sentinel) | 0..1 | string | Definition: Procedure.outcome.text Value Set: |
| followup-drainage | Drainage | 0..1 | string | Definition: Procedure.note.text Value Set: |
| followup-verband | Verband | 0..1 | string | Value Set: |
| followup-antibiotika | Antibiotikatherapie | 0..1 | string | Value Set: |
| followup-mobilisation | Mobilisation | 0..1 | string | Value Set: |
 followup-labor | Laborkontrolle | 0..1 | string | Value Set: |
 komplikation | Operative Komplikation | 0..1 | group | Value Set: |
 clavien-dindo | Clavien-Dindo-Grad | 0..1 | choice | Definition: Observation.valueCodeableConcept Value Set: Options: 5 options |
| komplikation-datum | Datum der Komplikation | 0..1 | date | Definition: Observation.effectiveDateTime Value Set: |
| komplikation-zeitpunkt | Zeitpunkt | 0..1 | choice | Definition: Observation.method Value Set: Options: 4 options |
| komplikation-art | Art der Komplikation (Freitext) | 0..1 | string | Definition: Observation.component.valueCodeableConcept.text Value Set: |
 komplikation-kommentar | Konsequenz / Kommentar | 0..1 | text | Definition: Observation.note.text Value Set: |
| Documentation for this format | ||||
Options Sets
Answer options for op-seite
- http://snomed.info/sct#80248007 ("Left breast structure")
- http://snomed.info/sct#73056007 ("Right breast structure")
- http://snomed.info/sct#63762007 ("Both breasts")
Answer options for op-intention
- https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention#K ("kurativ")
- https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention#P ("palliativ")
- https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention#D ("diagnostisch")
- https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention#R ("Revision/Komplikation")
- https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention#S ("sonstiges")
- https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention#X ("Fehlende Angabe")
Answer options for clavien-dindo
- http://snomed.info/sct#1367519000 ("Clavien-Dindo classification grade I")
- http://snomed.info/sct#1367520006 ("Clavien-Dindo classification grade II")
- http://snomed.info/sct#1367521005 ("Clavien-Dindo classification grade III")
- http://snomed.info/sct#1367524002 ("Clavien-Dindo classification grade IV")
- http://snomed.info/sct#1367527009 ("Clavien-Dindo classification grade V")
Answer options for komplikation-zeitpunkt
- Intraoperativ
- Postoperativ
- Stationaer
- Ambulant