LinkId Text Cardinality Type Flags Description & Constraints ClinicalResponseBaseline Clinical response questionnaire at baseline (first doctors' visit) Questionnaire http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/ClinicalResponseBaseline#1.0.0 General-Information-Clinical General information 1..1 group NA-Clinical What is the patient's medical record number? 1..1 string Expressions: Initial Value: %patient.id LastName-Clinical What is the patient's last name? 1..1 string Expressions: Initial Value: %patient.name.first().family.first() Demographics Demographic factors 1..1 group Sex Indicate the sex of the patient at birth: 1..1 choice Value Set: AdministrativeGender Expressions: Initial Value: %expandedGender.expansion.contains.where(code=%patient.gender) YearOfBirth In what year was the patient born? 1..1 integer Max Length: 4 Expressions: Initial Value: %patient.birthDate.substring(0,4) Clinical-Factors Clinical factors 1..1 group Height Indicate the patient's body height 1..1 quantity Weight Indicate the patient's weight. 1..1 quantity LATERAL Indicate the laterality of breast cancer 1..1 choice Value Set: Laterality of breast cancer ValueSet FIRSTBC Indicate if this is the first breast cancer 1..1 choice Value Set: Yes, No and Unknown Valueset NewBC Indicate if this is a new cancer on contralateral or ipsilateral breast 1..1 choice Enable When: FIRSTBC = No (expandedYes-NoIndicator#N) Value Set: Laterality of new cancer ValueSet Tumor-Factors Tumor factors 1..1 group HistologicalDateKnown Is the date of histological diagnosis known? 1..1 boolean HistologicalDiagnosisDate Indicate the initial date of histological diagnosis: 1..1 date Enable When: HistologicalDateKnown = true HISTOTYPE Indicate the histologic type of the tumor (select all that apply) 1..* choice Value Set: Histological type of the tumor ValueSet MUTBC Indicate if the patient carries a germline mutation predisposing breast cancer 1..* choice Value Set: Germline Mutation ValueSet GRADEINV Indicate the grade of the invasive component of tumor 1..1 choice Value Set: Grading of tumor ValueSet GRADEDCIS Indicate the tumor grade of DCIS component of tumor 1..1 choice Value Set: Grading of tumor ValueSet TNMCT_BREAST Indicate the clinical tumor stage (per AJCC 8th Ed.): 1..1 choice Value Set: TNM Primary Tumor ValueSet TNMCN_BREAST Indicate the clinical nodal stage (per AJCC 8th Ed.): 1..1 choice Value Set: TNM Regional Nodes ValueSet TNMCM_BREAST Indicate the clinical distant metastasis (per AJCC 8th Ed.): 1..1 choice Value Set: TNM Distant Metastases ValueSet ERSTATUS Indicate if the estrogen receptor status is positive: 1..1 choice Value Set: Estrogen receptor status ValueSet PRSTATUS Indicate if the progesterone receptor status is positive: 1..1 choice Value Set: Progesterone receptor status ValueSet HER2STATUS Indicate if the HER2 receptor status is positive: 1..1 choice Value Set: HER2 receptor status ValueSet MolecularProfiling Indicate if a molecular profiling tool was used. If so, which one? 1..1 choice Value Set: Molecular profiling Mammaprint Indicate the mammaprint score on a scale of 0.000 to 1.000 1..1 decimal Enable When: MolecularProfiling = Mammaprint Score (Molecular Profiling CodeSystem#mammaprint) Oncotype Indicate the oncotype score on a scale of 0 to 100 1..1 decimal Enable When: MolecularProfiling = Oncotype Score (Molecular Profiling CodeSystem#oncotype) Endopredict Indicate the endopredict score on a scale of 1.1 to 6.2 1..1 decimal Enable When: MolecularProfiling = Endopredict Score (Molecular Profiling CodeSystem#endopredict) Treatment-Variables Treatment variables 1..1 group MultMeet Indicate if a multidisciplinary meeting was conducted 1..1 choice Value Set: Yes, No and Unknown Valueset MultRecTreatments Which treatments did the multidisciplinary team recommend (select all that apply)? 1..* choice Enable When: MultMeet = Yes (expandedYes-NoIndicator#Y) Value Set: Recommended treatment types ValueSet Documentation for this format
Patient information to pre-populate the form with
Clinical response questionnaire at baseline
HL7 International - Clinical Interoperability Council Group
Clinical response questionnaire at baseline (first doctors' visit)
What is the patient's medical record number?
Indicate the sex of the patient at birth:
Indicate the laterality of breast cancer
Indicate if this is the first breast cancer
Indicate if this is a new cancer on contralateral or ipsilateral breast
Is the date of histological diagnosis known?
Indicate the initial date of histological diagnosis:
Indicate the histologic type of the tumor (select all that apply)
Indicate if the patient carries a germline mutation predisposing breast cancer
Indicate the grade of the invasive component of tumor
Indicate the tumor grade of DCIS component of tumor
Indicate the clinical tumor stage (per AJCC 8th Ed.):
Indicate the clinical nodal stage (per AJCC 8th Ed.):
Indicate the clinical distant metastasis (per AJCC 8th Ed.):
Indicate if the estrogen receptor status is positive:
Indicate if the progesterone receptor status is positive:
Indicate if the HER2 receptor status is positive:
Indicate if a molecular profiling tool was used. If so, which one?
Indicate the mammaprint score on a scale of 0.000 to 1.000
Indicate the oncotype score on a scale of 0 to 100
Indicate the endopredict score on a scale of 1.1 to 6.2
Indicate if a multidisciplinary meeting was conducted
Which treatments did the multidisciplinary team recommend (select all that apply)?