Implementierungsleitfaden Therapieziele Onkologie
1.0.0-ballot - Ballot
Germany
Implementierungsleitfaden Therapieziele Onkologie - Local Development build (v1.0.0-ballot) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Language: en
Bundle BundleMammaNeoadjuvant of type transaction
Entry 1 - fullUrl = http://example.org/fhir/Patient/PatientinMamma
Resso}:
Language: en
Sabine Baumann Female, DoB: 1977-06-24
Request:
POST Patient
Entry 2 - fullUrl = http://example.org/fhir/Practitioner/OnkologinMamma
Resso}:
Language: en
name: Katrin Musterarzt
Request:
POST Practitioner
Entry 3 - fullUrl = http://example.org/fhir/Organization/TumorzentrumMamma
Resso}:
Language: en
name: Zertifiziertes Brustzentrum Musterklinik
Request:
POST Organization
Entry 4 - fullUrl = http://example.org/fhir/Organization/Tumorboard
Resso}:
Language: en
identifier:
https://www.musterklinik.de/fhir/sid/organisationen/tumorboard-brust-001active: true
type: Organizational team
name: Zertifiziertes Brustzentrum Musterklinik
Request:
POST Organization
Entry 5 - fullUrl = http://example.org/fhir/ServiceRequest/ServiceRequestBiopsieMamma
Resso}:
Language: en
status: Completed
intent: Order
code: No display for ServiceRequest.code (concept: Core needle biopsy of breast (procedure))
subject: Sabine Baumann Female, DoB: 1977-06-24
authoredOn: 2025-09-12
requester: Practitioner Katrin Musterarzt
Request:
POST ServiceRequest
Entry 6 - fullUrl = http://example.org/fhir/ServiceRequest/ServiceRequestPathologieMamma
Resso}:
Language: en
status: Completed
intent: Order
code: No display for ServiceRequest.code (concept: Histopathology service (qualifier value))
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
Request:
POST ServiceRequest
Entry 7 - fullUrl = http://example.org/fhir/ServiceRequest/ServiceRequestStagingMamma
Resso}:
Language: en
status: Completed
intent: Order
code: No display for ServiceRequest.code (concept: )
subject: Sabine Baumann Female, DoB: 1977-06-24
authoredOn: 2025-09-15
requester: Practitioner Katrin Musterarzt
Request:
POST ServiceRequest
Entry 8 - fullUrl = http://example.org/fhir/ServiceRequest/ServiceRequestGBRCAMamma
Resso}:
Language: en
status: Completed
intent: Order
code: No display for ServiceRequest.code (concept: 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
Request:
POST ServiceRequest
Entry 9 - fullUrl = http://example.org/fhir/CarePlan/CarePlanMammaDiagnostik
Resso}:
Language: en
Profile: Diagnostischer CarePlan
status: Active
intent: Plan
category: Tumordiagnostik
subject: Sabine Baumann Female, DoB: 1977-06-24
addresses: No display for CarePlan.addresses (reference: ->Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse)
activity
activity
activity
activity
Request:
POST CarePlan
Entry 10 - fullUrl = http://example.org/fhir/Goal/DiagnosticGoal
Resso}:
Language: en
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
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
Request:
POST Goal
Entry 11 - fullUrl = http://example.org/fhir/Condition/ConditionMamma
Resso}:
Language: en
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
Request:
POST Condition
Entry 12 - fullUrl = http://example.org/fhir/Procedure/ProcedureBiopsieMamma
Resso}:
Language: en
status: Completed
category: Diagnostic procedure (procedure)
code: Sonografisch gesteuerte Stanzbiopsie der Mamma links
subject: Sabine Baumann Female, DoB: 1977-06-24
bodySite: Mamma links, oberer äußerer Quadrant
Request:
POST Procedure
Entry 13 - fullUrl = http://example.org/fhir/Specimen/SpecimenBiopsieMamma
Resso}:
Language: en
status: Available
type: Stanzbiopsat (Gewebeprobe) Mamma links
subject: Sabine Baumann Female, DoB: 1977-06-24
Collections
Collected[x] Method BodySite 2025-09-15 Core needle biopsy No display for Specimen.collection.bodySite (concept: Structure of upper outer quadrant of breast)
Request:
POST Specimen
Entry 14 - fullUrl = http://example.org/fhir/Observation/ObsHistologieMamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 15 - fullUrl = http://example.org/fhir/Observation/ObsGradingMamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 16 - fullUrl = http://example.org/fhir/Observation/ObsTNMklinischMamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 17 - fullUrl = http://example.org/fhir/Observation/ObsEstrogenrezeptorMamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 18 - fullUrl = http://example.org/fhir/Observation/ObsProgesteronrezeptorMamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 19 - fullUrl = http://example.org/fhir/Observation/ObsHER2Mamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 20 - fullUrl = http://example.org/fhir/Observation/ObsKi67Mamma
Resso}:
Language: en
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
Request:
POST Observation
Entry 21 - fullUrl = http://example.org/fhir/Observation/ObsGBRCAMamma
Resso}:
Language: en
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.
Request:
POST Observation
Entry 22 - fullUrl = http://example.org/fhir/EpisodeOfCare/TherapielinieChemo
Resso}:
Language: en
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-1EnLiST-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
Diagnoses
Condition No display for EpisodeOfCare.diagnosis.condition (reference: ->Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse) patient: Sabine Baumann Female, DoB: 1977-06-24
managingOrganization: Organization Zertifiziertes Brustzentrum Musterklinik
period: 2025-10-01 --> 2026-03-15
careManager: Practitioner Katrin Musterarzt
Request:
POST EpisodeOfCare
Entry 23 - fullUrl = http://example.org/fhir/EpisodeOfCare/TherapielinieOperation
Resso}:
Language: en
Profile: Onkologische Therapielinie
Onkologische Therapieintention (Extension)
- hauptintention: Curative - procedure intent
EnLiST-Zählstatus (Extension): Zählt nicht
status: Finished
type: Surgical procedure
Diagnoses
Condition No display for EpisodeOfCare.diagnosis.condition (reference: ->Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse) 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
Request:
POST EpisodeOfCare
Entry 24 - fullUrl = http://example.org/fhir/Goal/TherapiezielMammaHeilung
Resso}:
Language: en
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
Targets
Measure Due[x] Stage group.clinical Cancer 2026-04-15 addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
Request:
POST Goal
Entry 25 - fullUrl = http://example.org/fhir/ServiceRequest/ServiceRequestProcedure
Resso}:
Language: en
Profile: Tumorboard ServiceRequest
status: Active
intent: Proposal
category: Tumor board Consult note, Surgical procedure
code: No display for ServiceRequest.code (concept: Lumpectomy of breast (procedure))
Request:
POST ServiceRequest
Entry 26 - fullUrl = http://example.org/fhir/MedicationRequest/MedicationRequestPembroChemoNeoadjuvantMamma
Resso}:
Language: en
Profile: Tumorboard MedicationRequest
EnLiST-Änderungstyp (Extension): New LoT
status: Completed
intent: Plan
category: Tumor board Consult note
Request:
POST MedicationRequest
Entry 27 - fullUrl = http://example.org/fhir/MedicationAdministration/MedicationAdministrationPembroChemoNeoadjuvantMamma1
Resso}:
Language: en
status: completed
subject: Sabine Baumann Female, DoB: 1977-06-24
note:
Zyklus 1 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
Request:
POST MedicationAdministration
Entry 28 - fullUrl = http://example.org/fhir/MedicationAdministration/MedicationAdministrationPembroChemoNeoadjuvantMamma2
Resso}:
Language: en
status: completed
subject: Sabine Baumann Female, DoB: 1977-06-24
note:
Zyklus 2 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
Request:
POST MedicationAdministration
Entry 29 - fullUrl = http://example.org/fhir/MedicationAdministration/MedicationAdministrationPembroChemoNeoadjuvantMamma3
Resso}:
Language: en
status: completed
subject: Sabine Baumann Female, DoB: 1977-06-24
note:
Zyklus 3 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
Request:
POST MedicationAdministration
Entry 30 - fullUrl = http://example.org/fhir/MedicationAdministration/MedicationAdministrationPembroChemoNeoadjuvantMamma4
Resso}:
Language: en
status: completed
subject: Sabine Baumann Female, DoB: 1977-06-24
note:
Zyklus 4 von 4 (Pembro/Carbo q3w); begleitend wöchentliche Paclitaxel-Gaben, hier nicht einzeln erfasst
Request:
POST MedicationAdministration
Entry 31 - fullUrl = http://example.org/fhir/Procedure/ProcedureOperationMamma
Resso}:
Language: en
status: Completed
code: Brusterhaltende Operation (BET) links + Sentinel-Lymphknoten-Biopsie
Request:
POST Procedure
Entry 32 - fullUrl = http://example.org/fhir/Observation/ObsTNMpathologischMamma
Resso}:
Language: en
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)
Request:
POST Observation
Entry 33 - fullUrl = http://example.org/fhir/Observation/ObsDiseaseStatusMamma
Resso}:
Language: en
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.
Request:
POST Observation
Entry 34 - fullUrl = http://example.org/fhir/CarePlan/CarePlanMammaNeoadjuvant
Resso}:
Language: en
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)
addresses: No display for CarePlan.addresses (reference: ->Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse)
activity
activity
activity
activity
Request:
POST CarePlan
Entry 35 - fullUrl = http://example.org/fhir/Goal/FollowUpGoal
Resso}:
Language: en
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
addresses: Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse
Request:
POST Goal
Entry 36 - fullUrl = http://example.org/fhir/ServiceRequest/ServiceRequestMammographieNachsorge
Resso}:
Language: en
status: Active
intent: Plan
code: No display for ServiceRequest.code (concept: Mammografie)
subject: Sabine Baumann Female, DoB: 1977-06-24
occurrence: 2027-04-15
requester: Practitioner Katrin Musterarzt
Request:
POST ServiceRequest
Entry 37 - fullUrl = http://example.org/fhir/CarePlan/CarePlanMammaNachsorge
Resso}:
Language: en
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)
addresses: No display for CarePlan.addresses (reference: ->Condition Bösartige Neubildung: Oberer äußerer Quadrant der Brustdrüse)
activity
Request:
POST CarePlan