Logisches Modell des IQTIG-Datensatzes fuer das QS-Verfahren 18.1 Mammachirurgie (Spezifikation 2024 V05).

Der Datensatz besteht aus drei Teildatensaetzen:

• Teildatensatz Basis (B): Patienten- und Falldaten
• Teildatensatz Brust (BRUST): Brustspezifische Diagnose- und Befunddaten
• Teildatensatz Operation (O): Operation, Histologie, Pathologie, Resektionsstatus

Dieses Modell dient als Zielstruktur der FHIR StructureMaps fuer die Ableitung einer IQTIG-konformen QS-Meldung aus einem Senologie-FHIR-Bundle. Die Serialisierung (CSV / XML) ist nicht Bestandteil dieses Modells.

Patienten- und Falldaten

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Institutionskennzeichen (IKNR) der Einrichtung (9-stellig)

Standortkennung des entlassenden Krankenhauses (Standort-ID)

Betriebsstaettennummer (BSNR) bei ambulanter Leistung

Patientenpseudonym / Versicherten-ID (pseudonymisiert)

Vorgangsnummer / Fall-ID (eindeutige Kennung pro Fall)

Version des Datensatzes (z.B. 18.1_2024_V05)

Geburtsdatum der Patientin / des Patienten

Geschlecht: 1=maennlich, 2=weiblich, 8=X, 9=unbestimmt

Postleitzahl des Wohnorts (5-stellig)

Aufnahmedatum in die behandelnde Einrichtung

Aufnahmegrund nach Paragraph 301 SGB V (4-stellig)

Aufnahmeanlass: E=Einweisung, N=Notfall, V=Verlegung, G=Geburt, ...

Einwilligung zur Datenuebermittlung an Landesstelle/G-BA (0=nein, 1=ja, 9=unbekannt)

Entlassungsdatum aus der Einrichtung

Entlassungs-/Verlegungsgrund nach Paragraph 301 SGB V

Brustspezifische Diagnose- und Befunddaten; ein Eintrag je behandelter Seite

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Laufende Nummer des Brust-Teildatensatzes (Zuordnung zu Operation)

Seitenlokalisation: R=rechts, L=links, B=beidseits

Indikation des Eingriffs: 1=maligne, 2=DCIS, 3=benigne, 4=Risikoreduktion, 5=Rekonstruktion, 9=sonstige

ICD-10-GM-Kodierung der Diagnose

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ICD-10-GM-Code (z.B. C50.4)

ICD-10-GM-Version

Datum der Erstdiagnose

Praetherapeutische Tumorgroesse in mm (klinisch/bildgebend)

klinische T-Kategorie

klinische N-Kategorie

klinische M-Kategorie

klinisches UICC-Stadium

Eingesetzte bildgebende Methode: 1=Mammografie, 2=Sonografie, 3=MRT, 4=Tomosynthese, 9=sonstige

BI-RADS-Klassifikation (0-6)

Praeoperative histologische Sicherung: 0=nein, 1=Stanzbiopsie, 2=Vakuumbiopsie, 3=FNA, 4=Exzisionsbiopsie, 9=sonstige

Praeoperativer Befundcode (Pathologie): B1-B5 analog UK-NHSBSP

Praeoperative Drahtmarkierung/Lokalisation: 0=keine, 1=Mammografie, 2=Sonografie, 3=MRT, 9=sonstige

Neoadjuvante Therapie erhalten: 0=nein, 1=ja-Chemotherapie, 2=ja-endokrin, 3=ja-Antikoerper, 9=sonstige

Praetherapeutische Tumorkonferenzempfehlung vorhanden: 0=nein, 1=ja, 9=unbekannt

Daten zur operativen Behandlung; ein Eintrag je Eingriff

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Laufende Nummer des Operations-Teildatensatzes

Zuordnung zu einem Brust-Teildatensatz (laufende Nummer)

Datum der Operation

Seitenlokalisation der Operation: R=rechts, L=links, B=beidseits

OPS-Prozedurenkodes des Eingriffs

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

OPS-Kode, z.B. 5-870.a1

OPS-Version (z.B. 2024)

Art des Eingriffs: 1=BET, 2=Mastektomie einfach, 3=Mastektomie hautsparend, 4=Mastektomie nippelsparend, 5=Revision, 6=Wiederaufbau, 9=sonstige

Dignitaet intraoperativ: 1=maligne, 2=benigne, 3=unklar

Intraoperativer Schnellschnitt durchgefuehrt: 0=nein, 1=ja

Intraoperative Praeparatkontrolle (QI-3): 0=nein, 1=Mammografie, 2=Sonografie, 9=sonstige

ICD-O-3 Morphologie (Histologietyp)

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ICD-O-Morphologie-Code (z.B. 8500/3)

ICD-O-Version

Histopathologisches Grading: 1=G1, 2=G2, 3=G3, 4=G4, X=GX

Maximaler Durchmesser des invasiven Tumorherdes in mm

Maximaler Durchmesser der DCIS-Komponente in mm

Multifokalitaet: 0=nein, 1=multifokal, 2=multizentrisch, 9=unbekannt

Pathologische T-Kategorie

Pathologische N-Kategorie

Pathologische M-Kategorie

y-Symbol (nach neoadjuvanter Therapie): 0=nein, 1=ja

Pathologisches UICC-Stadium

Lymphgefaessinvasion: L0, L1, LX

Veneninvasion: V0, V1, V2, VX

Perineurale Invasion: Pn0, Pn1, PnX

Lokaler Residualstatus: R0, R1, R1is, R1cy, R2, RX

Gesamtresidualstatus: R0, R1, R2, RX

Sentinel-Lymphknoten-Biopsie durchgefuehrt: 0=nein, 1=ja

Anzahl untersuchter Lymphknoten (ohne Sentinel)

Anzahl befallener Lymphknoten (ohne Sentinel)

Anzahl untersuchter Sentinel-Lymphknoten

Anzahl befallener Sentinel-Lymphknoten

Axilladissektion durchgefuehrt: 0=nein, 1=ja

Oestrogenrezeptor: P=positiv, N=negativ, U=unbekannt

Progesteronrezeptor: P=positiv, N=negativ, U=unbekannt

HER2-Status: P=positiv, N=negativ, U=unbekannt

Intra-/postoperative Komplikationen

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Komplikationskuerzel (z.B. WUH=Wundheilungsstoerung, ABS=Abszess)

ICD-10-GM-Code der Komplikation (falls vorhanden)

Revisionsoperation waehrend des Aufenthalts: 0=nein, 1=ja

Logisches Modell des IQTIG-Datensatzes fuer das QS-Verfahren 18.1 Mammachirurgie (Spezifikation 2024 V05).

Der Datensatz besteht aus drei Teildatensaetzen:

• Teildatensatz Basis (B): Patienten- und Falldaten
• Teildatensatz Brust (BRUST): Brustspezifische Diagnose- und Befunddaten
• Teildatensatz Operation (O): Operation, Histologie, Pathologie, Resektionsstatus

Dieses Modell dient als Zielstruktur der FHIR StructureMaps fuer die Ableitung einer IQTIG-konformen QS-Meldung aus einem Senologie-FHIR-Bundle. Die Serialisierung (CSV / XML) ist nicht Bestandteil dieses Modells.

Patienten- und Falldaten

Institutionskennzeichen (IKNR) der Einrichtung (9-stellig)

Standortkennung des entlassenden Krankenhauses (Standort-ID)

Betriebsstaettennummer (BSNR) bei ambulanter Leistung

Patientenpseudonym / Versicherten-ID (pseudonymisiert)

Vorgangsnummer / Fall-ID (eindeutige Kennung pro Fall)

Version des Datensatzes (z.B. 18.1_2024_V05)

Geburtsdatum der Patientin / des Patienten

Geschlecht: 1=maennlich, 2=weiblich, 8=X, 9=unbestimmt

Postleitzahl des Wohnorts (5-stellig)

Aufnahmedatum in die behandelnde Einrichtung

Aufnahmegrund nach Paragraph 301 SGB V (4-stellig)

Aufnahmeanlass: E=Einweisung, N=Notfall, V=Verlegung, G=Geburt, ...

Einwilligung zur Datenuebermittlung an Landesstelle/G-BA (0=nein, 1=ja, 9=unbekannt)

Entlassungsdatum aus der Einrichtung

Entlassungs-/Verlegungsgrund nach Paragraph 301 SGB V

Brustspezifische Diagnose- und Befunddaten; ein Eintrag je behandelter Seite

Laufende Nummer des Brust-Teildatensatzes (Zuordnung zu Operation)

Seitenlokalisation: R=rechts, L=links, B=beidseits

Indikation des Eingriffs: 1=maligne, 2=DCIS, 3=benigne, 4=Risikoreduktion, 5=Rekonstruktion, 9=sonstige

ICD-10-GM-Kodierung der Diagnose

ICD-10-GM-Code (z.B. C50.4)

ICD-10-GM-Version

Datum der Erstdiagnose

Praetherapeutische Tumorgroesse in mm (klinisch/bildgebend)

klinische T-Kategorie

klinische N-Kategorie

klinische M-Kategorie

klinisches UICC-Stadium

Eingesetzte bildgebende Methode: 1=Mammografie, 2=Sonografie, 3=MRT, 4=Tomosynthese, 9=sonstige

BI-RADS-Klassifikation (0-6)

Praeoperative histologische Sicherung: 0=nein, 1=Stanzbiopsie, 2=Vakuumbiopsie, 3=FNA, 4=Exzisionsbiopsie, 9=sonstige

Praeoperativer Befundcode (Pathologie): B1-B5 analog UK-NHSBSP

Praeoperative Drahtmarkierung/Lokalisation: 0=keine, 1=Mammografie, 2=Sonografie, 3=MRT, 9=sonstige

Neoadjuvante Therapie erhalten: 0=nein, 1=ja-Chemotherapie, 2=ja-endokrin, 3=ja-Antikoerper, 9=sonstige

Praetherapeutische Tumorkonferenzempfehlung vorhanden: 0=nein, 1=ja, 9=unbekannt

Daten zur operativen Behandlung; ein Eintrag je Eingriff

Laufende Nummer des Operations-Teildatensatzes

Zuordnung zu einem Brust-Teildatensatz (laufende Nummer)

Datum der Operation

Seitenlokalisation der Operation: R=rechts, L=links, B=beidseits

OPS-Prozedurenkodes des Eingriffs

OPS-Kode, z.B. 5-870.a1

OPS-Version (z.B. 2024)

Art des Eingriffs: 1=BET, 2=Mastektomie einfach, 3=Mastektomie hautsparend, 4=Mastektomie nippelsparend, 5=Revision, 6=Wiederaufbau, 9=sonstige

Dignitaet intraoperativ: 1=maligne, 2=benigne, 3=unklar

Intraoperativer Schnellschnitt durchgefuehrt: 0=nein, 1=ja

Intraoperative Praeparatkontrolle (QI-3): 0=nein, 1=Mammografie, 2=Sonografie, 9=sonstige

ICD-O-3 Morphologie (Histologietyp)

ICD-O-Morphologie-Code (z.B. 8500/3)

ICD-O-Version

Histopathologisches Grading: 1=G1, 2=G2, 3=G3, 4=G4, X=GX

Maximaler Durchmesser des invasiven Tumorherdes in mm

Maximaler Durchmesser der DCIS-Komponente in mm

Multifokalitaet: 0=nein, 1=multifokal, 2=multizentrisch, 9=unbekannt

Pathologische T-Kategorie

Pathologische N-Kategorie

Pathologische M-Kategorie

y-Symbol (nach neoadjuvanter Therapie): 0=nein, 1=ja

Pathologisches UICC-Stadium

Lymphgefaessinvasion: L0, L1, LX

Veneninvasion: V0, V1, V2, VX

Perineurale Invasion: Pn0, Pn1, PnX

Lokaler Residualstatus: R0, R1, R1is, R1cy, R2, RX

Gesamtresidualstatus: R0, R1, R2, RX

Sentinel-Lymphknoten-Biopsie durchgefuehrt: 0=nein, 1=ja

Anzahl untersuchter Lymphknoten (ohne Sentinel)

Anzahl befallener Lymphknoten (ohne Sentinel)

Anzahl untersuchter Sentinel-Lymphknoten

Anzahl befallener Sentinel-Lymphknoten

Axilladissektion durchgefuehrt: 0=nein, 1=ja

Oestrogenrezeptor: P=positiv, N=negativ, U=unbekannt

Progesteronrezeptor: P=positiv, N=negativ, U=unbekannt

HER2-Status: P=positiv, N=negativ, U=unbekannt

Intra-/postoperative Komplikationen

Komplikationskuerzel (z.B. WUH=Wundheilungsstoerung, ABS=Abszess)

ICD-10-GM-Code der Komplikation (falls vorhanden)

Revisionsoperation waehrend des Aufenthalts: 0=nein, 1=ja

Logisches Modell des IQTIG-Datensatzes fuer das QS-Verfahren 18.1 Mammachirurgie (Spezifikation 2024 V05).

Der Datensatz besteht aus drei Teildatensaetzen:

• Teildatensatz Basis (B): Patienten- und Falldaten
• Teildatensatz Brust (BRUST): Brustspezifische Diagnose- und Befunddaten
• Teildatensatz Operation (O): Operation, Histologie, Pathologie, Resektionsstatus

Dieses Modell dient als Zielstruktur der FHIR StructureMaps fuer die Ableitung einer IQTIG-konformen QS-Meldung aus einem Senologie-FHIR-Bundle. Die Serialisierung (CSV / XML) ist nicht Bestandteil dieses Modells.

Patienten- und Falldaten

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Institutionskennzeichen (IKNR) der Einrichtung (9-stellig)

Standortkennung des entlassenden Krankenhauses (Standort-ID)

Betriebsstaettennummer (BSNR) bei ambulanter Leistung

Patientenpseudonym / Versicherten-ID (pseudonymisiert)

Vorgangsnummer / Fall-ID (eindeutige Kennung pro Fall)

Version des Datensatzes (z.B. 18.1_2024_V05)

Geburtsdatum der Patientin / des Patienten

Geschlecht: 1=maennlich, 2=weiblich, 8=X, 9=unbestimmt

Postleitzahl des Wohnorts (5-stellig)

Aufnahmedatum in die behandelnde Einrichtung

Aufnahmegrund nach Paragraph 301 SGB V (4-stellig)

Aufnahmeanlass: E=Einweisung, N=Notfall, V=Verlegung, G=Geburt, ...

Einwilligung zur Datenuebermittlung an Landesstelle/G-BA (0=nein, 1=ja, 9=unbekannt)

Entlassungsdatum aus der Einrichtung

Entlassungs-/Verlegungsgrund nach Paragraph 301 SGB V

Brustspezifische Diagnose- und Befunddaten; ein Eintrag je behandelter Seite

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Laufende Nummer des Brust-Teildatensatzes (Zuordnung zu Operation)

Seitenlokalisation: R=rechts, L=links, B=beidseits

Indikation des Eingriffs: 1=maligne, 2=DCIS, 3=benigne, 4=Risikoreduktion, 5=Rekonstruktion, 9=sonstige

ICD-10-GM-Kodierung der Diagnose

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ICD-10-GM-Code (z.B. C50.4)

ICD-10-GM-Version

Datum der Erstdiagnose

Praetherapeutische Tumorgroesse in mm (klinisch/bildgebend)

klinische T-Kategorie

klinische N-Kategorie

klinische M-Kategorie

klinisches UICC-Stadium

Eingesetzte bildgebende Methode: 1=Mammografie, 2=Sonografie, 3=MRT, 4=Tomosynthese, 9=sonstige

BI-RADS-Klassifikation (0-6)

Praeoperative histologische Sicherung: 0=nein, 1=Stanzbiopsie, 2=Vakuumbiopsie, 3=FNA, 4=Exzisionsbiopsie, 9=sonstige

Praeoperativer Befundcode (Pathologie): B1-B5 analog UK-NHSBSP

Praeoperative Drahtmarkierung/Lokalisation: 0=keine, 1=Mammografie, 2=Sonografie, 3=MRT, 9=sonstige

Neoadjuvante Therapie erhalten: 0=nein, 1=ja-Chemotherapie, 2=ja-endokrin, 3=ja-Antikoerper, 9=sonstige

Praetherapeutische Tumorkonferenzempfehlung vorhanden: 0=nein, 1=ja, 9=unbekannt

Daten zur operativen Behandlung; ein Eintrag je Eingriff

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Laufende Nummer des Operations-Teildatensatzes

Zuordnung zu einem Brust-Teildatensatz (laufende Nummer)

Datum der Operation

Seitenlokalisation der Operation: R=rechts, L=links, B=beidseits

OPS-Prozedurenkodes des Eingriffs

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

OPS-Kode, z.B. 5-870.a1

OPS-Version (z.B. 2024)

Art des Eingriffs: 1=BET, 2=Mastektomie einfach, 3=Mastektomie hautsparend, 4=Mastektomie nippelsparend, 5=Revision, 6=Wiederaufbau, 9=sonstige

Dignitaet intraoperativ: 1=maligne, 2=benigne, 3=unklar

Intraoperativer Schnellschnitt durchgefuehrt: 0=nein, 1=ja

Intraoperative Praeparatkontrolle (QI-3): 0=nein, 1=Mammografie, 2=Sonografie, 9=sonstige