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

Generated Narrative: Questionnaire senologie-verlauf

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
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" QuestVerlaufFragebogen zur strukturierten Dokumentation der Verlaufskontrolle und Nachsorge. Nutzt SDC Template-based Extraction mit contained Templates für Klinischen Status und Tumorstatus.Questionnairehttps://www.senologie.org/fhir/Questionnaire/senologie-verlauf#0.9.0
\".\"\".\"\".\" kontrollterminKontrolltermin1..1group
\".\"\".\"\".\"\".\" kontrolltermin-datumDatum Vorstellung1..1date
\".\"\".\"\".\"\".\" kontrolltermin-artArt der Kontrolle1..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" kontrolltermin-art-nachsorgeArt der Nachsorge1..1choiceOptions: 2 options
\".\"\".\"\".\"\".\" kontrolltermin-monate-seit-edMonate seit Erstdiagnose0..1integer
\".\"\".\"\".\" klinischer-statusKlinischer Status0..1group
\".\"\".\"\".\"\".\" klinisch-allgemeinzustandAllgemeinzustand0..1choiceOptions: 3 options
\".\"\".\"\".\"\".\" klinisch-lokalbefundLokalbefund Brust0..1choiceOptions: 2 options
\".\"\".\"\".\"\".\" klinisch-lokalbefund-beschreibungLokalbefund Beschreibung0..1textEnable When: klinisch-lokalbefund = Auffällig
\".\"\".\"\".\"\".\" klinisch-lymphoedemLymphödem0..1choiceOptions: 4 options
\".\"\".\"\".\"\".\" klinisch-armumfangsdifferenzArmumfangsdifferenz (cm)0..1decimal
\".\"\".\"\".\"\".\" klinisch-schmerzenSchmerzen0..1boolean
\".\"\".\"\".\" tumorstatusTumorstatus0..1group
\".\"\".\"\".\"\".\" tumorstatus-gesamtbeurteilungGesamtbeurteilung Verlauf0..1choiceOptions: 5 options
\".\"\".\"\".\"\".\" tumorstatus-lokalrezidivLokalrezidiv0..1boolean
\".\"\".\"\".\"\".\" tumorstatus-rezidiv-datumDatum Rezidiv0..1dateEnable When: tumorstatus-lokalrezidiv = true
\".\"\".\"\".\"\".\" tumorstatus-fernmetastasenFernmetastasen0..1boolean
\".\"\".\"\".\"\".\" tumorstatus-metastasen-lokalisationMetastasenlokalisation0..*choiceEnable When: tumorstatus-fernmetastasen = true
Options: 5 options
\".\"\".\"\".\" weiteres-vorgehenWeiteres Vorgehen0..1group
\".\"\".\"\".\"\".\" vorgehen-naechster-terminNächster Kontrolltermin0..1date
\".\"\".\"\".\"\".\" vorgehen-empfehlungEmpfehlung0..1text

\"doco\" Documentation for this format

Options Sets

Answer options for kontrolltermin-art

Answer options for kontrolltermin-art-nachsorge

Answer options for klinisch-allgemeinzustand

Answer options for klinisch-lokalbefund

Answer options for klinisch-lymphoedem

Answer options for tumorstatus-gesamtbeurteilung

Answer options for tumorstatus-metastasen-lokalisation

Contained Resources

Observation #verlauf-klinisch-template

status: Final

code: Klinischer Status Verlauf

subject: ?rref?

Observation #verlauf-tumorstatus-template

status: Final

code: Tumorstatus Verlauf

subject: ?rref?

" }, "contained" : [{ "resourceType" : "Observation", "id" : "verlauf-klinisch-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "11323-3", "display" : "Health status" }], "text" : "Klinischer Status Verlauf" }, "subject" : { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue", "valueString" : "%patient" }] } }, { "resourceType" : "Observation", "id" : "verlauf-tumorstatus-template", "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "88040-1", "display" : "Response to cancer treatment" }], "text" : "Tumorstatus Verlauf" }, "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-verlauf", "version" : "0.9.0", "name" : "QuestVerlauf", "title" : "Fragebogen: Verlaufsdokumentation / Nachsorge", "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 Verlaufskontrolle und Nachsorge. Nutzt SDC Template-based Extraction mit contained Templates für Klinischen Status und Tumorstatus.", "item" : [{ "linkId" : "kontrolltermin", "text" : "Kontrolltermin", "type" : "group", "required" : true, "item" : [{ "linkId" : "kontrolltermin-datum", "text" : "Datum Vorstellung", "type" : "date", "required" : true }, { "linkId" : "kontrolltermin-art", "text" : "Art der Kontrolle", "type" : "choice", "required" : true, "answerOption" : [{ "valueString" : "6-Monats-Kontrolle" }, { "valueString" : "12-Monats-Kontrolle" }, { "valueString" : "Außerplanmäßig" }, { "valueString" : "Abschlusskontrolle" }] }, { "linkId" : "kontrolltermin-art-nachsorge", "text" : "Art der Nachsorge", "type" : "choice", "required" : true, "answerOption" : [{ "valueString" : "Aktiv (persönlich untersucht)" }, { "valueString" : "Passiv (aus Akten/Registern)" }] }, { "linkId" : "kontrolltermin-monate-seit-ed", "text" : "Monate seit Erstdiagnose", "type" : "integer", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#verlauf-klinisch-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "klinischer-status", "text" : "Klinischer Status", "type" : "group", "required" : false, "item" : [{ "linkId" : "klinisch-allgemeinzustand", "code" : [{ "system" : "http://snomed.info/sct", "code" : "365275006", "display" : "General well-being finding" }], "text" : "Allgemeinzustand", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "Gut" }, { "valueString" : "Eingeschränkt" }, { "valueString" : "Schlecht" }] }, { "linkId" : "klinisch-lokalbefund", "code" : [{ "system" : "http://snomed.info/sct", "code" : "116339002", "display" : "Breast finding" }], "text" : "Lokalbefund Brust", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "Unauffällig" }, { "valueString" : "Auffällig" }] }, { "linkId" : "klinisch-lokalbefund-beschreibung", "text" : "Lokalbefund Beschreibung", "type" : "text", "enableWhen" : [{ "question" : "klinisch-lokalbefund", "operator" : "=", "answerString" : "Auffällig" }], "required" : false }, { "linkId" : "klinisch-lymphoedem", "code" : [{ "system" : "http://snomed.info/sct", "code" : "449620005", "display" : "Lymphedema of upper limb" }], "text" : "Lymphödem", "type" : "choice", "required" : false, "answerOption" : [{ "valueString" : "Kein" }, { "valueString" : "Grad I" }, { "valueString" : "Grad II" }, { "valueString" : "Grad III" }] }, { "linkId" : "klinisch-armumfangsdifferenz", "code" : [{ "system" : "http://snomed.info/sct", "code" : "301712009", "display" : "Arm circumference" }], "text" : "Armumfangsdifferenz (cm)", "type" : "decimal", "required" : false }, { "linkId" : "klinisch-schmerzen", "code" : [{ "system" : "http://snomed.info/sct", "code" : "22253000", "display" : "Pain" }], "text" : "Schmerzen", "type" : "boolean", "required" : false }] }, { "extension" : [{ "extension" : [{ "url" : "template", "valueReference" : { "reference" : "#verlauf-tumorstatus-template" } }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract" }], "linkId" : "tumorstatus", "text" : "Tumorstatus", "type" : "group", "required" : false, "item" : [{ "linkId" : "tumorstatus-gesamtbeurteilung", "text" : "Gesamtbeurteilung Verlauf", "type" : "choice", "required" : false, "answerOption" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "103338009", "display" : "In full remission" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "103337004", "display" : "In partial remission" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "58158008", "display" : "Stable" } }, { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "271299001", "display" : "Tumor progression" } }, { "valueString" : "Kein Anhalt für Tumor" }] }, { "linkId" : "tumorstatus-lokalrezidiv", "code" : [{ "system" : "http://snomed.info/sct", "code" : "363346000", "display" : "Malignant neoplastic disease" }], "text" : "Lokalrezidiv", "type" : "boolean", "required" : false }, { "linkId" : "tumorstatus-rezidiv-datum", "code" : [{ "system" : "http://snomed.info/sct", "code" : "432213005", "display" : "Date of diagnosis" }], "text" : "Datum Rezidiv", "type" : "date", "enableWhen" : [{ "question" : "tumorstatus-lokalrezidiv", "operator" : "=", "answerBoolean" : true }], "required" : false }, { "linkId" : "tumorstatus-fernmetastasen", "code" : [{ "system" : "http://snomed.info/sct", "code" : "399409002", "display" : "Distant metastasis present" }], "text" : "Fernmetastasen", "type" : "boolean", "required" : false }, { "linkId" : "tumorstatus-metastasen-lokalisation", "code" : [{ "system" : "http://snomed.info/sct", "code" : "385421009", "display" : "Site of distant metastasis" }], "text" : "Metastasenlokalisation", "type" : "choice", "enableWhen" : [{ "question" : "tumorstatus-fernmetastasen", "operator" : "=", "answerBoolean" : true }], "required" : false, "repeats" : true, "answerOption" : [{ "valueString" : "Lunge" }, { "valueString" : "Leber" }, { "valueString" : "Knochen" }, { "valueString" : "Hirn" }, { "valueString" : "Sonstige" }] }] }, { "linkId" : "weiteres-vorgehen", "text" : "Weiteres Vorgehen", "type" : "group", "required" : false, "item" : [{ "linkId" : "vorgehen-naechster-termin", "text" : "Nächster Kontrolltermin", "type" : "date", "required" : false }, { "linkId" : "vorgehen-empfehlung", "text" : "Empfehlung", "type" : "text", "required" : false }] }] }