German
Generated Narrative: ServiceRequest ServiceRequestBiopsieMamma
status: Completed
intent: Order
code: Core needle biopsy of breast (procedure)
subject: Sabine Baumann Female, DoB: 1977-06-24
authoredOn: 2025-09-12
requester: Practitioner Katrin Musterarzt
German
Generated Narrative: ServiceRequest ServiceRequestPathologieMamma
status: Completed
intent: Order
code: Histopathologische Untersuchung inkl. Rezeptor-/HER2-Status und Ki-67
subject: Sabine Baumann Female, DoB: 1977-06-24
authoredOn: 2025-09-15
requester: Practitioner Katrin Musterarzt
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: ServiceRequest ServiceRequestStagingMamma
status: Completed
intent: Order
code: Klinische Ausbreitungsdiagnostik / TNM-Staging
subject: Sabine Baumann Female, DoB: 1977-06-24
authoredOn: 2025-09-15
requester: Practitioner Katrin Musterarzt
German
Generated Narrative: ServiceRequest ServiceRequestGBRCAMamma
status: Completed
intent: Order
code: BRCA1 gene mutations tested for in Blood or Tissue by Molecular genetics method Nominal
subject: Sabine Baumann Female, DoB: 1977-06-24
authoredOn: 2025-09-18
requester: Practitioner Katrin Musterarzt
German
Generated Narrative: CarePlan CarePlanMammaDiagnostik
Profile: Diagnostischer CarePlan
status: Active
intent: Plan
category: Tumordiagnostik
subject: Sabine Baumann Female, DoB: 1977-06-24
author: Practitioner Katrin Musterarzt
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
activity
outcomeReference: Procedure Core needle biopsy of breast (procedure)
reference: ServiceRequest Core needle biopsy of breast (procedure)
activity
outcomeReference:
- Observation Histology and Behavior ICD-O-3 Cancer
- Observation Histologic grade [Score] in Breast cancer specimen by Nottingham
- Observation Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain
- Observation Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain
- Observation HER2 Ag [Interpretation] in Tissue
- Observation Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
reference: ServiceRequest Histopathology service (qualifier value)
activity
outcomeReference: Observation Stage group.clinical Cancer
reference: ServiceRequest
activity
outcomeReference: Observation BRCA1 gene mutations tested for in Blood or Tissue by Molecular genetics method Nominal
German
Generated Narrative: Goal DiagnosticGoal
Profile: Onkologisches Therapieziel
Goal acceptance
- individual: Sabine Baumann Female, DoB: 1977-06-24
- status: agree
- priority: High Priority
lifecycleStatus: Active
achievementStatus: In Progress
category: Diagnostic intent
priority: High Priority
description: Diagnosesicherung für die Verdachtsdiagnose
subject: Sabine Baumann Female, DoB: 1977-06-24
start: 2025-09-12
target
measure: Primary tumor.clinical [Class] Cancer
target
measure: Regional lymph nodes.clinical [Class] Cancer
target
measure: Distant metastases.clinical [Class] Cancer
target
measure: Stage group.clinical Cancer
target
measure: Estrogen receptor Ag [Presence] in Tissue by Immune stain
target
measure: Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain
target
measure: HER2 Ag [Interpretation] in Tissue
target
measure: Primary site Cancer
target
measure: Histologic grade [Score] in Breast cancer specimen by Nottingham
target
measure: Histology grade [Identifier] in Cancer specimen
target
measure: Sentinel lymph nodes examined [#] in Cancer specimen by Light microscopy
expressedBy: Practitioner Katrin Musterarzt
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
outcomeReference: Observation Cancer disease progression
German
Generated Narrative: Condition ConditionMamma
Profile: Onkologische Diagnose (Condition)
Condition Asserted Date: 2025-09-15
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Invasives Mammakarzinom links, oberer äußerer Quadrant (NST), triple-negativ
bodySite: Mamma links, oberer äußerer Quadrant
subject: Sabine Baumann Female, DoB: 1977-06-24
onset: 2025-09-15
recordedDate: 2025-09-15
German
Generated Narrative: Procedure ProcedureBiopsieMamma
status: Completed
category: Diagnostic procedure (procedure)
code: Sonografisch gesteuerte Stanzbiopsie der Mamma links
subject: Sabine Baumann Female, DoB: 1977-06-24
performed: 2025-09-15
reasonReference: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
bodySite: Mamma links, oberer äußerer Quadrant
German
Generated Narrative: Specimen SpecimenBiopsieMamma
status: Available
type: Stanzbiopsat (Gewebeprobe) Mamma links
subject: Sabine Baumann Female, DoB: 1977-06-24
| Collected[x] | Method | BodySite |
| 2025-09-15 | Core needle biopsy | Mamma links, oberer äußerer Quadrant |
German
Generated Narrative: Observation ObsHistologieMamma
status: Final
code: Histology and Behavior ICD-O-3 Cancer
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-15
value: Invasives Mammakarzinom, NST (ICD-O-3 8500/3)
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: Observation ObsGradingMamma
status: Final
code: Histologic grade [Score] in Breast cancer specimen by Nottingham
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-15
value: G3 – schlecht differenziert (Elston-Ellis)
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: Observation ObsTNMklinischMamma
status: Final
code: Stage group.clinical Cancer
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-16
value: cT2 cN1 cM0 – UICC IIB
German
Generated Narrative: Observation ObsEstrogenrezeptorMamma
status: Final
code: Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-17
value: Negative
note:
Immunhistochemie: <1 % positive Kerne → ER-negativ.
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: Observation ObsProgesteronrezeptorMamma
status: Final
code: Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-17
value: Negative
note:
Immunhistochemie: <1 % positive Kerne → PR-negativ.
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: Observation ObsHER2Mamma
status: Final
code: HER2 Ag [Interpretation] in Tissue
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-17
value: Negative
note:
Immunhistochemie 1+ → HER2-negativ; keine In-situ-Hybridisierung erforderlich.
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: Observation ObsKi67Mamma
status: Final
code: Ki-67 Proliferationsindex (MIB-1)
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-17
value: 70 % (Details: UCUM code% = '%')
specimen: Specimen: status = available; type = Specimen from breast obtained by core needle biopsy
German
Generated Narrative: Observation ObsGBRCAMamma
status: Final
code: BRCA1 gene mutations tested for in Blood or Tissue by Molecular genetics method Nominal
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-09-25
value: Negative
note:
gBRCA1/2: keine (wahrscheinlich) pathogene Variante (Klasse 4/5) nachgewiesen.
German
Generated Narrative: EpisodeOfCare TherapielinieChemo
Profile: Onkologische Therapielinie
Onkologische Therapieintention (Extension)
- hauptintention: Neoadjuvant intent
- phase: Curative - procedure intent
EnLiST-LoT-Designation (Extension)
- setting: eLoT — frühes Setting
- line: 1
- modification: 0
- notation: eLoT 1.0
- lineId:
https://bih-cei.de/fhir/therapieziele-onkologie/sid/enlist-line/mamma-baumann-elot-1
EnLiST-Zählstatus (Extension): Zählt in der LoT-Zählung
Therapielinie – Medikationsverordnung (Extension): MedicationRequest: extension = New LoT; status = completed; intent = plan; category = Tumor board Consult note; medication[x] =
status: Finished
type: Chemotherapy care
| Condition | Role | Rank |
| Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse | Chief complaint | 1 |
patient: Sabine Baumann Female, DoB: 1977-06-24
managingOrganization: Organization Zertifiziertes Brustzentrum Musterklinik
period: 2025-10-01 --> 2026-03-15
careManager: Practitioner Katrin Musterarzt
German
Generated Narrative: EpisodeOfCare TherapielinieOperation
Profile: Onkologische Therapielinie
Onkologische Therapieintention (Extension)
- hauptintention: Curative - procedure intent
EnLiST-Zählstatus (Extension): Zählt nicht
status: Finished
type: Surgical procedure
| Condition | Role | Rank |
| Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse | Chief complaint | 1 |
patient: Sabine Baumann Female, DoB: 1977-06-24
managingOrganization: Organization Zertifiziertes Brustzentrum Musterklinik
period: 2026-03-20 --> 2026-04-06
referralRequest: ServiceRequest Lumpectomy of breast (procedure)
careManager: Practitioner Katrin Musterarzt
German
Generated Narrative: Goal TherapiezielMammaHeilung
Profile: Onkologisches Therapieziel
Onkologische Therapieintention (Extension)
- hauptintention: Curative - procedure intent
Goal acceptance
- individual: Sabine Baumann Female, DoB: 1977-06-24
- status: agree
- priority: High Priority
Goal: Related Goal
Goal: Related Goal
lifecycleStatus: Active
achievementStatus: Achieved
category: Heilung, Funktionserhalt
priority: High Priority
description: Kurative Behandlung des frühen triple-negativen Mammakarzinoms mittels neoadjuvanter Systemtherapie und brusterhaltender Operation; Erreichen einer pathologischen Komplettremission (pCR).
subject: Sabine Baumann Female, DoB: 1977-06-24
start: 2025-09-22
| Measure | Due[x] |
| Stage group.clinical Cancer | 2026-04-15 |
expressedBy: Practitioner Katrin Musterarzt
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
outcomeReference: Observation Cancer disease progression
German
Generated Narrative: ServiceRequest ServiceRequestProcedure
Profile: Tumorboard ServiceRequest
status: Active
intent: Proposal
category: Tumor board Consult note, Surgical procedure
code: Lumpectomy of breast (procedure)
German
Generated Narrative: MedicationRequest MedicationRequestPembroChemoNeoadjuvantMamma
Profile: Tumorboard MedicationRequest
EnLiST-Änderungstyp (Extension): New LoT
status: Completed
intent: Plan
category: Tumor board Consult note
medication: Pembrolizumab + Carboplatin/Paclitaxel, gefolgt von Pembrolizumab + Epirubicin/Cyclophosphamid (KEYNOTE-522)
German
Generated Narrative: MedicationAdministration MedicationAdministrationPembroChemoNeoadjuvantMamma1
status: Completed
medication: Pembrolizumab + Carboplatin (q3w), Paclitaxel wöchentlich begleitend (KEYNOTE-522, Phase 1)
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-10-01
note:
Zyklus 1 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
German
Generated Narrative: MedicationAdministration MedicationAdministrationPembroChemoNeoadjuvantMamma2
status: Completed
medication: Pembrolizumab + Carboplatin (q3w), Paclitaxel wöchentlich begleitend (KEYNOTE-522, Phase 1)
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2025-11-01
note:
Zyklus 2 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
German
Generated Narrative: MedicationAdministration MedicationAdministrationPembroChemoNeoadjuvantMamma3
status: Completed
medication: Pembrolizumab + Carboplatin (q3w), Paclitaxel wöchentlich begleitend (KEYNOTE-522, Phase 1)
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2026-02-10
note:
Zyklus 3 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
German
Generated Narrative: MedicationAdministration MedicationAdministrationPembroChemoNeoadjuvantMamma4
status: Completed
medication: Pembrolizumab + Carboplatin (q3w), Paclitaxel wöchentlich begleitend (KEYNOTE-522, Phase 1)
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2026-03-15
note:
Zyklus 4 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
German
Generated Narrative: Procedure ProcedureOperationMamma
status: Completed
code: Brusterhaltende Operation (BET) links + Sentinel-Lymphknoten-Biopsie
subject: Sabine Baumann Female, DoB: 1977-06-24
performed: 2026-04-02
German
Generated Narrative: Observation ObsTNMpathologischMamma
status: Final
code: Stage group.pathology Cancer
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2026-04-07
value: ypT0 ypN0 – pathologische Komplettremission (pCR)
German
Generated Narrative: Observation ObsDiseaseStatusMamma
status: Final
code: Cancer disease progression
subject: Sabine Baumann Female, DoB: 1977-06-24
effective: 2026-04-07
value: Not detected
note:
Pathologische Komplettremission (pCR, ypT0 ypN0) nach neoadjuvanter Systemtherapie.
German
Generated Narrative: CarePlan CarePlanMammaNeoadjuvant
Profile: Onkologischer CarePlan
CarePlan Custodian (Extension): Organization Zertifiziertes Brustzentrum Musterklinik
status: Active
intent: Plan
category: Cancer care plan
subject: Sabine Baumann Female, DoB: 1977-06-24
period: 2025-09-22 --> (ongoing)
author: Practitioner Katrin Musterarzt
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
activity
outcomeReference:
- MedicationAdministration: status = completed; medication[x] = ; effective[x] = 2025-10-01; note = Zyklus 1 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
- MedicationAdministration: status = completed; medication[x] = ; effective[x] = 2025-11-01; note = Zyklus 2 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
- MedicationAdministration: status = completed; medication[x] = ; effective[x] = 2026-02-10; note = Zyklus 3 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
- MedicationAdministration: status = completed; medication[x] = ; effective[x] = 2026-03-15; note = Zyklus 4 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
activity
outcomeReference: Procedure Lumpectomy of breast (procedure)
activity
activity
outcomeReference: Observation Cancer disease progression
German
Generated Narrative: Goal FollowUpGoal
Profile: Onkologisches Therapieziel
Goal acceptance
- individual: Sabine Baumann Female, DoB: 1977-06-24
- status: agree
- priority: High Priority
Goal: Related Goal
Goal: Related Goal
lifecycleStatus: Planned
achievementStatus: In Progress
category: Lebensqualität
priority: High Priority
description: Monitoring der Lebensqualität und des Krankheitsstatus nach der onkologischen Erkrankung und Therapie
subject: Sabine Baumann Female, DoB: 1977-06-24
start: 2026-08-15
target
measure: Cancer outcome status
detail: Kein Hinweis auf Lokalrezidiv oder Fernmetastasen
due: 2026-11-15
target
measure: Mammografie
detail: Unauffällige Nachsorge-Mammographie (jährlich), kein Rezidivnachweis
due: 2027-04-15
target
measure: Arm-/Schulterfunktion und Lymphödem-Status nach axillärem Eingriff
detail: Kein manifestes Lymphödem, erhaltene Schulterbeweglichkeit
target
measure: Gesundheitsbezogene Lebensqualität (PROM, EORTC QLQ-C30 / BR23) – MII PRO-Modul
detail: Stabile bis verbesserte Lebensqualität im Verlauf
expressedBy: Practitioner Katrin Musterarzt
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
outcomeReference: Observation Cancer disease progression
German
Generated Narrative: ServiceRequest ServiceRequestMammographieNachsorge
status: Active
intent: Plan
code: Nachsorge-Mammographie beidseits (jährlich)
subject: Sabine Baumann Female, DoB: 1977-06-24
occurrence: 2027-04-15
requester: Practitioner Katrin Musterarzt
reasonReference: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
German
Generated Narrative: CarePlan CarePlanMammaNachsorge
Profile: Onkologischer CarePlan
CarePlan Custodian (Extension): Organization Zertifiziertes Brustzentrum Musterklinik
status: Active
intent: Plan
category: Cancer care plan
subject: Sabine Baumann Female, DoB: 1977-06-24
period: 2026-08-15 --> (ongoing)
author: Practitioner Katrin Musterarzt
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
| Reference |
| ServiceRequest Mammografie |