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Mammakarzinom.","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","marks":[{"type":"alignment","attrs":{"align":"center"}}],"content":[{"text":"-","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","marks":[{"type":"alignment","attrs":{"align":"center"}}],"content":[{"text":"-","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[101.0]},"content":[{"type":"paragraph","content":[{"text":"Modul_Darm","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[93.0]},"content":[{"type":"paragraph","content":[{"text":"Modul_Darm_Typ_patho","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[62.0]},"content":[{"type":"paragraph","content":[{"text":"minOccurs=\"0\"","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[298.0]},"content":[{"type":"paragraph","content":[{"text":"Zusatzangaben bei vorliegendem kolorektalem Karzinom.","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","marks":[{"type":"alignment","attrs":{"align":"center"}}],"content":[{"text":"-","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","marks":[{"type":"alignment","attrs":{"align":"center"}}],"content":[{"text":"-","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[101.0]},"content":[{"type":"paragraph","content":[{"text":"Modul_Prostata","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[93.0]},"content":[{"type":"paragraph","content":[{"text":"Modul_Prostata_Typ_patho","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[62.0]},"content":[{"type":"paragraph","content":[{"text":"minOccurs=\"0\"","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[298.0]},"content":[{"type":"paragraph","content":[{"text":"Zusatzangaben bei vorliegendem 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bei vorliegendem malignem Melanom.","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","marks":[{"type":"alignment","attrs":{"align":"center"}}],"content":[{"text":"-","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","marks":[{"type":"alignment","attrs":{"align":"center"}}],"content":[{"text":"-","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[101.0]},"content":[{"type":"paragraph","content":[{"text":"Modul_DKKR","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[93.0]},"content":[{"type":"paragraph"}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[62.0]},"content":[{"type":"paragraph","content":[{"text":"minOccurs=\"0\"","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[298.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[48.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[101.0]},"content":[{"type":"paragraph","content":[{"text":"Befund_ID","type":"text","marks":[{"type":"subsup","attrs":{"type":"sup"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[93.0]},"content":[{"type":"paragraph"}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[62.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[298.0]},"content":[{"type":"paragraph","content":[{"text":"Optionale Angabe einer ID zur erleichterten Zuordnung. Die Befund-ID sollte Fälle im Primärsystem eindeutig identifizieren.","type":"text"}]}]}]}]},{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"XML-Schema","type":"text"}]},{"type":"heading","attrs":{"level":5},"content":[{"text":"Pathologie_Typ","type":"text","marks":[{"type":"strong"}]}]},{"type":"codeBlock","attrs":{"language":"xml"},"content":[{"text":"\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\tHöchste erreichte Diagnosesicherheit zum Diagnosedatum (siehe BfArM, ICD-O-3.2: Ergänzende Informationen, Abschnitt 4.5. \"Sicherheit der Diagnose\").\n\t\t\t\tohne 1 = Klinisch ohne tumorspezifische Diagnostik (nur körperliche Untersuchung) \n\t\t\t\tohne 2 = Klinisch: Klinische Diagnose vor dem Sterbedatum durchgeführt; schließt diagnostische Techniken, inklusive Röntgen, Endoskopie, weitere bildgebende Verfahren, Ultraschall, exploratorische Chirurgie (Laparatomie, etc.) und Autopsie, ohne mikroskopische Gewebediagnose, ein. \n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tSpezifische Tumormarker\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tZytologisch: Untersuchung von Zellen aus primären Lokalisationen inklusive Flüssigkeitsaspirationen mittels Endoskopien oder Nadeln. Schließt mikroskopische Untersuchungen von peripheren Blutausstrichen und Ausstrichen von Beckenkammaspirationen ein.\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tHistologie Metastase (Ausprägung ist veraltet, besser 7.2 nutzen)\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tHistologie Primärtumor (Ausprägung ist veraltet, besser 7.1 nutzen)\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tHistologie des Primärtumors: Histologische Untersuchung von Gewebe des Primärtumors\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tHistologie Metastase: Histologische Untersuchung des Gewebes aus einer Metastase\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tHistologie der Autopsie: Histologische Untersuchung des Gewebes bei einer Autopsie\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tZytogenetisch und/oder molekularer Test\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tUnbekannt\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\t\n\t\t\t\t\tPrätherapeutisches TNM\n\t\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\t\n\t\t\t\t\tPostoperatives TNM. Es ist nicht nötig, dass alle Bestandteile der TNM-Formel die Einstufung 'p' aufweisen.\n\t\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\tStrukturierte, bevorzugte Form\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\tNicht strukturierte, alternative Form\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\t\n\t\t\t\t\tVollständiger Befundbericht des Pathologen (Originalbenennung \"Befund\")\n\t\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Beispieldatensatz","type":"text"}]},{"type":"heading","attrs":{"level":5},"content":[{"text":"Beispieldatensatz (oBDS_v3.0.0 Build 2022-01-19_1)","type":"text","marks":[{"type":"strong"}]}]},{"type":"codeBlock","attrs":{"language":"xml"},"content":[{"text":"\n \n ...\n \n 2021-07-19\n \n \n \n ...\n \n \n \n D\n \n \n C50.8\n 10 2021 GM\n \n 2018-08-01\n T\n \n \n\t\t\t\t\t\tMammakarzinom\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tC50.8\n\t\t\t\t\t\t\t33\n\t\t\t\t\t\t\n\t\t\t\t\t\täußerer oberer und äußerer unterer Quadrant\n\t\t\t\t\t\t7\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\n\t\t\t\t\t\tR0\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n \t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tDr.\n\t\t\t\t\t\t\t\tErnst\n\t\t\t\t\t\t\t\tMüller \n\t\t\t\t\t\t\t\tPraxis 1\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tWeg\n\t\t\t\t\t\t\t\t1\n\t\t\t\t\t\t\t\tDE\n\t\t\t\t\t\t\t\t30173\n\t\t\t\t\t\t\t\tHannover\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\tPathologisch-anatomische Untersuchung und Begutachtung\n\t\t\t\t\t\tKlinischer Befund: Verdacht auf Prostatacarcinom, Prostatabiopsate beidseits, PSA-Wert: 25,6 ng/ml\n\t\t\t\t\t\tMakroskopischer Befund: 1. - 10. Prostatastanzbiopsien rechts (1. – 6.) und links (7. – 10.), jeweils basal lateral, basal medial, Mitte lateral, Mitte medial, \t\n\t\t\t\t\t\tapikal lateral, apikal medial.\n\t\t\t\t\t\tZehn Stanzen von 2 bis 11 mm Länge gem. Anlage. Färbung: HE, PAS.\n\t\t\t\t\t\tMikroskopischer Befund: \n\t\t\t\t\t\t1. Mikroskopisch in allen Stufenschnitten aus der Stanze ein leicht nodulär umgebautes Gewebe mit\n\t\t\t\t\t\terweiterten und hyperplastischen Drüsen.\n\t\t\t\t\t\t2. Mikroskopisch in der Stanze wie in der Biopsie 1.\n\t\t\t\t\t\t3. Mikroskopisch in der Stanze vorwiegend Befund wie in der Biopsie 1, an einer kleinen Stelle finden sich\n\t\t\t\t\t\twenige auffällige Drüsen zwischen den hyperplastischen Azini.\n\t\t\t\t\t\t4. Mikroskopisch auch in dieser Stanze und randständig ein kleines Infiltrat aus auffälligen Drüsen mit \n\t\t\t\t\t\teinem kubischen, basophilen Epithel.\n\t\t\t\t\t\t5. Befund wie 1.\n\t\t\t\t\t\t6. Befund wie 3.\n\t\t\t\t\t\t7. In der Stanze finden sich fusionierte Drüsen mit schwach ausgebildeten Drüsenlichtungen, daneben\n\t\t\t\t\t\tauch kribriforme Drüsen mit einem basophilen Epithel, die atypischen Drüsen bilden unscharf begrenzte\n\t\t\t\t\t\tTumorherde.\n\t\t\t\t\t\t8. Mikroskopisch in der gesamten Stanze gleichartige Tumorinfiltrate wie in der Stanze 7.\n\t\t\t\t\t\t9. Befund wie 1.\n\t\t\t\t\t\t10. Befund wie 3.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\t...\n\t\t\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\t \n\t\t\t\t\n \n \n \n \n \n ...\n \n","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Datenmodell","type":"text"}]},{"type":"expand","attrs":{"title":"Pathologie"},"content":[{"type":"mediaSingle","attrs":{"layout":"full-width"},"content":[{"type":"media","attrs":{"width":4406,"id":"c95d81b4-d1c5-4b82-86d1-e7a7364d0de1","collection":"contentId-15532102","type":"file","height":5771}}]}]},{"type":"heading","attrs":{"level":1},"content":[{"text":"Informationen zur Belegung","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Diagnosedatum","type":"text"}]},{"type":"paragraph","content":[{"text":"Die Angabe des Diagnosedatums in einer Pathologiemeldung haben einer Priorität zu folgen → siehe ","type":"text"},{"text":"Tumorzuordnung_Typ","type":"text","marks":[{"type":"link","attrs":{"href":"/wiki/spaces/UMK/pages/15532201"}}]},{"text":".","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Hinweis zum Befundbericht","type":"text"}]},{"type":"paragraph","content":[{"text":"Mit Bezug auf die Histologie_EinsendeNr. ist stets der vollständige Befundbericht des Pathologen als Befundtext zu melden, d.h. der Befundbericht (Prosatext und Schlüssel), den auch der Einsender/behandelnde Arzt erhält. Es ist sicherzustellen, dass auch alle Nachbefunde zum eingesendeten Material gemeldet werden. Gleiches gilt für Zusatzbefunde (z.B. Zweitmeinungen, Zusatzuntersuchungen, etc.), die bei anderen Pathologen/Leistungserbringern beauftragt wurden. Die Meldung des Befundes ersetzt nicht die strukturierte Meldung für diejenigen Inhalte, für die in der XML ein strukturierter Eintrag möglich ist.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Metastase eines bekannten Primarius vs. C80.9 (CUP – Carcinoma of unknown primary)","type":"text"}]},{"type":"paragraph","content":[{"text":"Wird in einem Präparat eindeutig eine Metastase diagnostiziert und der Primärtumor ist bekannt, so ist die Lokalisation des Primärtumors in der ICD-O anzugeben. Ist der Primärtumor nicht bekannt, ist seine Lokalisation in der ICD-O als C80.9 anzugeben. Die Lokalisation der Metastase wird in ","type":"text"},{"text":"Menge_FM_Typ","type":"text","marks":[{"type":"link","attrs":{"href":"/wiki/spaces/UMK/pages/15532896"}}]},{"text":" übermittelt.","type":"text"}]},{"type":"paragraph","content":[{"text":"Beachten Sie dazu auch die Hinweise unter ","type":"text"},{"text":"Meldepflichtige Diagnosen nach ICD","type":"text","marks":[{"type":"link","attrs":{"href":"https://plattform65c.atlassian.net/wiki/spaces/UMK/pages/15532944"}}]},{"text":".","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Pro Tumor eine separate Meldung","type":"text"}]},{"type":"paragraph","content":[{"text":"Regelmäßig (wenn auch nicht extrem häufig) werden im Befundmaterial einer Histologie_EinsendeNr mehrere Tumoren gefunden (z.B. inzidentes Prostata-Ca bei Harnblasen-Ca). Die Register erwarten hier für jeden Tumor eine separate Meldung mit den jeweiligen Kodierungen. Bei Schwierigkeiten mit der Umsetzung ist eine Vereinbarung mit der Plattform § 65c zu treffen.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Befund_ID","type":"text"}]},{"type":"paragraph","content":[{"text":"Hier kann der ggf. vom erzeugenden System geführte Identifikator eines zugrundeliegenden Pathologie-Datensatzes übermittelt werden. Dies erleichtert den Registern die Zuordnung und kann Rückfragen vermeiden. Die Befund_ID muss für den Melder eindeutig sein.","type":"text"}]},{"type":"paragraph","content":[{"text":"Bitte beachten Sie auch die ","type":"text"},{"text":"Hinweise zu den ID Feldern","type":"text","marks":[{"type":"link","attrs":{"href":"https://plattform65c.atlassian.net/wiki/spaces/UMK/pages/15532570"}}]},{"text":".","type":"text"}]},{"type":"paragraph","content":[{"type":"hardBreak"}]},{"type":"paragraph","content":[{"type":"hardBreak"}]},{"type":"paragraph","content":[{"type":"hardBreak"}]},{"type":"paragraph","content":[{"type":"hardBreak"}]}],"version":1}

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