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

Generated Narrative: Questionnaire senologie-postop

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
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" QuestPostOPDokumentationFragebogen 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).Questionnairehttps://www.senologie.org/fhir/Questionnaire/senologie-postop#0.9.0
\".\"\".\"\".\" bezugsdiagnoseBezugsdiagnose (Seite)1..1reference
\".\"\".\"\".\" operationOperative Therapie1..1group
\".\"\".\"\".\"\".\" op-kategorieArt der Operation1..1choiceDefinition: Procedure.category
Value Set: BIH LM Senologie Operation
\".\"\".\"\".\"\".\" op-seiteSeite1..1choiceDefinition: Procedure.bodySite
Options: 3 options
\".\"\".\"\".\"\".\" op-datumOP-Datum1..1dateDefinition: Procedure.performedDateTime
\".\"\".\"\".\"\".\" op-code-textBeschreibung der OP (Freitext, z.B. "BET links, Sentinel-LK-Biopsie")0..1stringDefinition: Procedure.code.text
\".\"\".\"\".\"\".\" op-intentionOP-Intention0..1choiceDefinition: Procedure.extension:Intention.valueCodeableConcept
Options: 6 options
\".\"\".\"\".\"\".\" op-outcomeOP-Outcome (z.B. R-Status, Sentinel)0..1stringDefinition: Procedure.outcome.text
\".\"\".\"\".\"\".\" followup-drainageDrainage0..1stringDefinition: Procedure.note.text
\".\"\".\"\".\"\".\" followup-verbandVerband0..1string
\".\"\".\"\".\"\".\" followup-antibiotikaAntibiotikatherapie0..1string
\".\"\".\"\".\"\".\" followup-mobilisationMobilisation0..1string
\".\"\".\"\".\"\".\" followup-laborLaborkontrolle0..1string
\".\"\".\"\".\" komplikationOperative Komplikation0..1group
\".\"\".\"\".\"\".\" clavien-dindoClavien-Dindo-Grad0..1choiceDefinition: Observation.valueCodeableConcept
Options: 5 options
\".\"\".\"\".\"\".\" komplikation-datumDatum der Komplikation0..1dateDefinition: Observation.effectiveDateTime
\".\"\".\"\".\"\".\" komplikation-zeitpunktZeitpunkt0..1choiceDefinition: Observation.method
Options: 4 options
\".\"\".\"\".\"\".\" komplikation-artArt der Komplikation (Freitext)0..1stringDefinition: Observation.component.valueCodeableConcept.text
\".\"\".\"\".\"\".\" komplikation-kommentarKonsequenz / Kommentar0..1textDefinition: Observation.note.text

\"doco\" Documentation for this format

Options Sets

Answer options for op-seite

Answer options for op-intention

Answer options for clavien-dindo

Answer options for komplikation-zeitpunkt

Contained Resources

Procedure #postop-procedure-template

Profile: BIH LM Senologie Brustwand-Operation

status: Completed

subject: placeholder

Observation #postop-komplikation-template

Profile: BIH Senologie Operative Komplikation

status: Final

code: Clavien-Dindo classification grade

subject: placeholder

" }, "contained" : [{ "resourceType" : "Procedure", "id" : "postop-procedure-template", "meta" : { "profile" : ["https://www.senologie.org/fhir/StructureDefinition/senologie-operation"] }, "status" : "completed", "subject" : { "reference" : "placeholder" }, "reasonReference" : [{ "reference" : "placeholder", "_reference" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "item.where(linkId='bezugsdiagnose').answer.valueReference.reference" }] } }] }, { "resourceType" : "Observation", "id" : "postop-komplikation-template", "meta" : { "profile" : ["https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation"] }, "status" : "final", "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "789279006", "display" : "Clavien-Dindo classification grade" }] }, "subject" : { "reference" : "placeholder" } }], "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-postop", "version" : "0.9.0", "name" : "QuestPostOPDokumentation", "title" : "Fragebogen: Postoperative Dokumentation", "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 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).", "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 }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#postop-procedure-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "operation", "text" : "Operative Therapie", "type" : "group", "required" : true, "item" : [{ "linkId" : "op-kategorie", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.category", "text" : "Art der Operation", "type" : "choice", "required" : true, "answerValueSet" : "https://www.senologie.org/fhir/ValueSet/vs-senologie-operation-art" }, { "linkId" : "op-seite", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.bodySite", "text" : "Seite", "type" : "choice", "required" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "80248007", "display" : "Left breast structure" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "73056007", "display" : "Right breast structure" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "63762007", "display" : "Both breasts" } }] }, { "linkId" : "op-datum", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.performedDateTime", "text" : "OP-Datum", "type" : "date", "required" : true }, { "linkId" : "op-code-text", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.code.text", "text" : "Beschreibung der OP (Freitext, z.B. \"BET links, Sentinel-LK-Biopsie\")", "type" : "string", "required" : false }, { "linkId" : "op-intention", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.extension:Intention.valueCodeableConcept", "text" : "OP-Intention", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention", "code" : "K", "display" : "kurativ" } }, { "valueCoding" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention", "code" : "P", "display" : "palliativ" } }, { "valueCoding" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention", "code" : "D", "display" : "diagnostisch" } }, { "valueCoding" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention", "code" : "R", "display" : "Revision/Komplikation" } }, { "valueCoding" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention", "code" : "S", "display" : "sonstiges" } }, { "valueCoding" : { "system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention", "code" : "X", "display" : "Fehlende Angabe" } }] }, { "linkId" : "op-outcome", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.outcome.text", "text" : "OP-Outcome (z.B. R-Status, Sentinel)", "type" : "string", "required" : false }, { "linkId" : "followup-drainage", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operation#Procedure.note.text", "text" : "Drainage", "type" : "string", "required" : false }, { "linkId" : "followup-verband", "text" : "Verband", "type" : "string", "required" : false }, { "linkId" : "followup-antibiotika", "text" : "Antibiotikatherapie", "type" : "string", "required" : false }, { "linkId" : "followup-mobilisation", "text" : "Mobilisation", "type" : "string", "required" : false }, { "linkId" : "followup-labor", "text" : "Laborkontrolle", "type" : "string", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#postop-komplikation-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "komplikation", "text" : "Operative Komplikation", "type" : "group", "required" : false, "item" : [{ "linkId" : "clavien-dindo", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation#Observation.valueCodeableConcept", "text" : "Clavien-Dindo-Grad", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1367519000", "display" : "Clavien-Dindo classification grade I" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1367520006", "display" : "Clavien-Dindo classification grade II" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1367521005", "display" : "Clavien-Dindo classification grade III" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1367524002", "display" : "Clavien-Dindo classification grade IV" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1367527009", "display" : "Clavien-Dindo classification grade V" } }] }, { "linkId" : "komplikation-datum", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation#Observation.effectiveDateTime", "text" : "Datum der Komplikation", "type" : "date", "required" : false }, { "linkId" : "komplikation-zeitpunkt", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation#Observation.method", "text" : "Zeitpunkt", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "Intraoperativ" }, { "valueString" : "Postoperativ" }, { "valueString" : "Stationaer" }, { "valueString" : "Ambulant" }] }, { "linkId" : "komplikation-art", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation#Observation.component.valueCodeableConcept.text", "text" : "Art der Komplikation (Freitext)", "type" : "string", "required" : false }, { "linkId" : "komplikation-kommentar", "definition" : "https://www.senologie.org/fhir/StructureDefinition/senologie-operative-komplikation#Observation.note.text", "text" : "Konsequenz / Kommentar", "type" : "text", "required" : false }] }] }