Lithuanian Colorectal Cancer Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Colorectal Cancer Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-colorectal/ and changes regularly. See the Directory of published versions

Questionnaire: ESPBI Colonoscopy Form

Oficialus URL: https://hl7.lt/fhir/colorectal/Questionnaire/questionnaire-colonoscopy-espbi Versija: 0.0.1
Mašiniškai apdorojamas pavadinimas: QuestionnaireColonoscopyEspbi

ESPBI form for colonoscopy in the Lithuanian colorectal cancer screening programme.

Language: en

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. QuestionnaireColonoscopyEspbi ESPBI form for colonoscopy in the Lithuanian colorectal cancer screening programme. Questionnaire https://hl7.lt/fhir/colorectal/Questionnaire/questionnaire-colonoscopy-espbi#0.0.1
... basicInfo Basic descriptive part 0..1 group Value Set:
.... basicInfo.postponedColonoscopy Was colonoscopy postponed for screening? 0..1 boolean Value Set:
.... basicInfo.anesthesia Anesthesia 0..1 coding Value Set:
Options: 2 options
.... basicInfo.videoColonoscope Video colonoscope used? 0..1 coding Value Set:
Options: 2 options
.... basicInfo.withdrawalTime Withdrawal time (minutes) 0..1 integer Value Set:
.... basicInfo.procedureDate Procedure date 0..1 dateTime Value Set:
.... basicInfo.retroflexionRectum Retroflexion in the rectum 0..1 coding Value Set:
Options: 3 options
.... basicInfo.previousAbdominalSurgery History of major abdominal surgery 0..1 coding Value Set:
Options: 2 options
.... basicInfo.previousAbdominalSurgeryDetails Previous abdominal surgery details 0..1 text Enable When: basicInfo.previousAbdominalSurgery = Yes (SNOMED CT#373066001)
Value Set:
... bowelPrep Bowel preparation assessment 0..1 group Value Set:
.... bowelPrep.prepQuality Bowel preparation quality adequate? 0..1 coding Value Set:
Options: 2 options
.... bowelPrep.bbpsRight BBPS Right colon / ascending (0-3) 0..1 integer Value Set:
.... bowelPrep.bbpsTransverse BBPS Transverse colon (0-3) 0..1 integer Value Set:
.... bowelPrep.bbpsLeft BBPS Left colon / descending + sigmoid (0-3) 0..1 integer Value Set:
.... bowelPrep.totalBbps Total BBPS score (0-9) 0..1 integer Value Set:
.... bowelPrep.dietaryRecommendations Were dietary recommendations given? 0..1 coding Value Set:
Options: 2 options
.... bowelPrep.splitDose Was split-dose protocol used? 0..1 coding Value Set:
Options: 2 options
.... bowelPrep.prepMethod Preparation method 0..1 coding Value Set:
Options: 2 options
.... bowelPrep.lastDoseHoursBeforeProcedure Last dose timing (hours before procedure) 0..1 integer Value Set:
.... bowelPrep.writtenInfo Was written information about preparation given? 0..1 coding Value Set:
Options: 2 options
.... bowelPrep.usedPreparations Used preparations for bowel preparation 0..* coding Value Set:
Options: 4 options
... scopeReach Colonoscope reach 0..1 group Value Set:
.... scopeReach.reachLocation Deepest point reached by colonoscope 0..1 coding Value Set:
Options: 11 options
.... polypFindings.polypFound Polyp found? 0..1 boolean Value Set:
.... polypFindings.location Polyp location 0..1 coding Value Set:
Options: 10 options
.... polypFindings.sizeMm Polyp size (mm) 0..1 integer Value Set:
.... polypFindings.parisClassification Paris endoscopic classification 0..1 coding Value Set:
Options: 9 options
.... polypFindings.niceClassification NICE classification 0..1 coding Value Set:
Options: 3 options
.... polypFindings.predictedHistology Predicted histology 0..1 coding Value Set:
Options: 4 options
.... polypFindings.locationSide Location side 0..1 coding Value Set:
Options: 2 options
.... polypFindings.accessDifficulty Access difficulty 0..1 coding Value Set:
Options: 2 options
.... polypFindings.smsaScore SMSA total score 0..1 integer Value Set:
.... polypFindings.smsaLevel SMSA level 0..1 coding Value Set:
Options: 4 options
.... polypFindings.polypRemoved Was polyp removed? 0..1 coding Value Set:
Options: 2 options
.... polypFindings.removalMethod Removal method 0..1 coding Enable When: polypFindings.polypRemoved = Yes (SNOMED CT#373066001)
Value Set:
Options: 6 options
.... polypFindings.lumenFilling Lumen filling method 0..1 coding Enable When: polypFindings.polypRemoved = Yes (SNOMED CT#373066001)
Value Set:
Options: 3 options
.... polypFindings.resectionType Resection type 0..1 coding Enable When: polypFindings.polypRemoved = Yes (SNOMED CT#373066001)
Value Set:
Options: 2 options
.... polypFindings.hydropreparation Hydropreparation substances used 0..* coding Enable When: polypFindings.polypRemoved = Yes (SNOMED CT#373066001)
Value Set:
Options: 4 options
.... polypFindings.complicationAfterRemoval Complication after polyp removal? 0..1 coding Value Set:
Options: 2 options
.... polypFindings.allPolypsRemovedSimultaneously All polyps removed simultaneously? 0..1 coding Value Set:
Options: 2 options
.... polypFindings.sentForHistology Sent for histological examination? 0..1 coding Value Set:
Options: 2 options
... tumorFindings Tumor findings 0..* group Value Set:
.... tumorFindings.tumorFound Tumor found? 0..1 boolean Value Set:
.... tumorFindings.tumorLocation Tumor location 0..1 coding Value Set:
Options: 10 options
.... tumorFindings.tumorDescription Tumor description 0..1 text Value Set:
.... tumorFindings.biopsyPerformed Biopsy performed? 0..1 coding Value Set:
Options: 2 options
.... tumorFindings.biopsyPostponed Biopsy postponed? 0..1 coding Value Set:
Options: 2 options
... complications Complications after colonoscopy 0..1 group Value Set:
.... complications.complicationPresence Were there complications? 0..1 coding Value Set:
Options: 2 options
.... complications.complicationType Complication type 0..1 coding Enable When: complications.complicationPresence = Yes (SNOMED CT#373066001)
Value Set:
Options: 5 options
.... complications.wallInjury Wall injury (Sydney classification) 0..1 coding Enable When: complications.complicationPresence = Yes (SNOMED CT#373066001)
Value Set:
Options: 5 options
.... complications.actionTaken Action taken 0..1 coding Enable When: complications.complicationPresence = Yes (SNOMED CT#373066001)
Value Set:
Options: 3 options
.... complications.bleedingControl Bleeding control details 0..1 text Enable When: complications.complicationPresence = Yes (SNOMED CT#373066001)
Value Set:
... conclusions Final conclusions 0..1 group Value Set:
.... conclusions.conclusion Conclusion 0..1 coding Value Set:
Options: 7 options
.... conclusions.conclusionNotes Conclusion notes 0..1 text Value Set:
... recommendations Follow-up recommendations 0..1 group Value Set:
.... recommendations.nextColonoscopy Recommended interval for next colonoscopy 0..1 coding Value Set:
Options: 5 options
.... recommendations.additionalNotes Additional notes 0..1 text Value Set:
... signatures Signatures 0..1 group Value Set:
.... signatures.examinerName Examiner first name 1..1 string Value Set:
.... signatures.examinerSurname Examiner surname 1..1 string Value Set:
.... signatures.examDate Examination date 1..1 dateTime Value Set:

doco Documentation for this format

Options Sets

Answer options for basicInfo.anesthesia

  • http://snomed.info/sct#398166005 ("Performed")
  • http://snomed.info/sct#385660001 ("Not done")

Answer options for basicInfo.videoColonoscope

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for basicInfo.retroflexionRectum

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")
  • http://snomed.info/sct#48031000087101 ("Postponed")

Answer options for basicInfo.previousAbdominalSurgery

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for bowelPrep.prepQuality

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for bowelPrep.dietaryRecommendations

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for bowelPrep.splitDose

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for bowelPrep.prepMethod

  • null#null ("Two-day split preparation")
  • null#null ("Same-day non-split preparation")

Answer options for bowelPrep.writtenInfo

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for bowelPrep.usedPreparations

  • http://snomed.info/sct#712567003 ("Macrogol 4000 (substance)")
  • http://snomed.info/sct#712566007 ("Macrogol 3350 (substance)")
  • http://snomed.info/sct#715699009 ("Product containing citric acid and magnesium oxide and sodium picosulfate (medicinal product)")
  • http://snomed.info/sct#69958001 ("Sodium sulfate (substance)")

Answer options for scopeReach.reachLocation

  • http://snomed.info/sct#34402009 ("Rectum structure (body structure)")
  • http://snomed.info/sct#60184004 ("Sigmoid colon structure (body structure)")
  • http://snomed.info/sct#32622004 ("Descending colon structure (body structure)")
  • http://snomed.info/sct#72592005 ("Structure of left colic flexure (body structure)")
  • http://snomed.info/sct#485005 ("Transverse colon structure (body structure)")
  • http://snomed.info/sct#48338005 ("Structure of right colic flexure (body structure)")
  • http://snomed.info/sct#9040008 ("Ascending colon structure (body structure)")
  • http://snomed.info/sct#32713005 ("Cecum structure (body structure)")
  • http://snomed.info/sct#34516001 ("Ileal structure (body structure)")
  • http://snomed.info/sct#85774003 ("Structure of distal portion of ileum (body structure)")
  • http://snomed.info/sct#181261002 ("Entire rectum (body structure)")

Answer options for polypFindings.location

  • http://snomed.info/sct#34402009 ("Rectum structure (body structure)")
  • http://snomed.info/sct#60184004 ("Sigmoid colon structure (body structure)")
  • http://snomed.info/sct#32622004 ("Descending colon structure (body structure)")
  • http://snomed.info/sct#72592005 ("Structure of left colic flexure (body structure)")
  • http://snomed.info/sct#485005 ("Transverse colon structure (body structure)")
  • http://snomed.info/sct#48338005 ("Structure of right colic flexure (body structure)")
  • http://snomed.info/sct#9040008 ("Ascending colon structure (body structure)")
  • http://snomed.info/sct#32713005 ("Cecum structure (body structure)")
  • http://snomed.info/sct#34516001 ("Ileal structure (body structure)")
  • http://snomed.info/sct#85774003 ("Structure of distal portion of ileum (body structure)")

Answer options for polypFindings.parisClassification

  • null#null ("I-p Pedunculated")
  • null#null ("I-sp Semi-pedunculated")
  • null#null ("I-s Sessile")
  • null#null ("IIa Slightly elevated")
  • null#null ("IIb Flat")
  • null#null ("IIc Slightly depressed")
  • null#null ("III Excavated")
  • null#null ("LST-G Granular laterally spreading")
  • null#null ("LST-NG Non-granular laterally spreading")

Answer options for polypFindings.niceClassification

  • null#null ("Type I (Hyperplastic)")
  • null#null ("Type II (Adenoma)")
  • null#null ("Type III (Invasive)")

Answer options for polypFindings.predictedHistology

  • null#null ("Hyperplastic")
  • null#null ("Sessile serrated lesion (SSL)")
  • null#null ("Adenoma")
  • null#null ("Adenoma with suspicion of malignancy")

Answer options for polypFindings.locationSide

  • null#null ("Left side")
  • null#null ("Right side")

Answer options for polypFindings.accessDifficulty

  • null#null ("Easy")
  • null#null ("Difficult")

Answer options for polypFindings.smsaLevel

  • null#null ("Level 1 (4-5 points)")
  • null#null ("Level 2 (6-8 points)")
  • null#null ("Level 3 (9-12 points)")
  • null#null ("Level 4 (>12 points)")

Answer options for polypFindings.polypRemoved

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for polypFindings.removalMethod

  • null#null ("Cold forceps")
  • null#null ("Cold snare")
  • null#null ("Hot snare")
  • null#null ("EMR")
  • null#null ("ESD")
  • null#null ("Piecemeal EMR")

Answer options for polypFindings.lumenFilling

  • null#null ("Air insufflation")
  • null#null ("Water immersion")
  • null#null ("CO2 insufflation")

Answer options for polypFindings.resectionType

  • null#null ("En bloc resection")
  • null#null ("Piecemeal resection")

Answer options for polypFindings.hydropreparation

  • null#null ("Normal saline")
  • null#null ("Adrenaline")
  • null#null ("Methylene blue")
  • null#null ("Gelofusine")

Answer options for polypFindings.complicationAfterRemoval

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for polypFindings.allPolypsRemovedSimultaneously

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for polypFindings.sentForHistology

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for tumorFindings.tumorLocation

  • http://snomed.info/sct#34402009 ("Rectum structure (body structure)")
  • http://snomed.info/sct#60184004 ("Sigmoid colon structure (body structure)")
  • http://snomed.info/sct#32622004 ("Descending colon structure (body structure)")
  • http://snomed.info/sct#72592005 ("Structure of left colic flexure (body structure)")
  • http://snomed.info/sct#485005 ("Transverse colon structure (body structure)")
  • http://snomed.info/sct#48338005 ("Structure of right colic flexure (body structure)")
  • http://snomed.info/sct#9040008 ("Ascending colon structure (body structure)")
  • http://snomed.info/sct#32713005 ("Cecum structure (body structure)")
  • http://snomed.info/sct#34516001 ("Ileal structure (body structure)")
  • http://snomed.info/sct#85774003 ("Structure of distal portion of ileum (body structure)")

Answer options for tumorFindings.biopsyPerformed

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for tumorFindings.biopsyPostponed

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for complications.complicationPresence

  • http://snomed.info/sct#373066001 ("Yes")
  • http://snomed.info/sct#373067005 ("No")

Answer options for complications.complicationType

  • null#null ("Perforation")
  • null#null ("Bleeding")
  • null#null ("Post-polypectomy syndrome")
  • null#null ("Cardiopulmonary")
  • null#null ("Other")

Answer options for complications.wallInjury

  • null#null ("Type I - Superficial mucosal injury")
  • null#null ("Type II - Deep mucosal injury")
  • null#null ("Type III - Muscularis propria injury")
  • null#null ("Type IV - Serosal injury")
  • null#null ("Type V - Transmural perforation")

Answer options for complications.actionTaken

  • null#null ("Conservative management")
  • null#null ("Endoscopic treatment")
  • null#null ("Surgical intervention")

Answer options for conclusions.conclusion

  • null#null ("Normal")
  • null#null ("Polyps found")
  • null#null ("Polyps and diverticulosis")
  • null#null ("Diverticulosis")
  • null#null ("Tumor found")
  • null#null ("Inflammatory bowel disease")
  • null#null ("Other pathology")

Answer options for recommendations.nextColonoscopy

  • null#null ("1 year")
  • null#null ("3 years")
  • null#null ("5 years")
  • null#null ("10 years")
  • null#null ("Not applicable")

Language: en

Basic descriptive part

  • linkId: basicInfo
  • Answers:

Was colonoscopy postponed for screening?

  • linkId: basicInfo.postponedColonoscopy
  • Answers:

Anesthesia

Video colonoscope used?

Withdrawal time (minutes)

  • linkId: basicInfo.withdrawalTime
  • Answers:

Procedure date

  • linkId: basicInfo.procedureDate
  • Answers:

Retroflexion in the rectum

History of major abdominal surgery

Previous abdominal surgery details

  • linkId: basicInfo.previousAbdominalSurgeryDetails
  • Enable When: todo
  • Answers:

Bowel preparation assessment

  • linkId: bowelPrep
  • Answers:

Bowel preparation quality adequate?

BBPS Right colon / ascending (0-3)

  • linkId: bowelPrep.bbpsRight
  • Answers:

BBPS Transverse colon (0-3)

  • linkId: bowelPrep.bbpsTransverse
  • Answers:

BBPS Left colon / descending + sigmoid (0-3)

  • linkId: bowelPrep.bbpsLeft
  • Answers:

Total BBPS score (0-9)

  • linkId: bowelPrep.totalBbps
  • Answers:

Were dietary recommendations given?

Was split-dose protocol used?

Preparation method

Last dose timing (hours before procedure)

  • linkId: bowelPrep.lastDoseHoursBeforeProcedure
  • Answers:

Was written information about preparation given?

Used preparations for bowel preparation

Colonoscope reach

  • linkId: scopeReach
  • Answers:

Deepest point reached by colonoscope

Polyp findings

  • linkId: polypFindings
  • Answers:

Polyp found?

  • linkId: polypFindings.polypFound
  • Answers:

Polyp location

Polyp size (mm)

  • linkId: polypFindings.sizeMm
  • Answers:

Paris endoscopic classification

NICE classification

Predicted histology

Location side

Access difficulty

SMSA total score

  • linkId: polypFindings.smsaScore
  • Answers:

SMSA level

Was polyp removed?

Removal method

Lumen filling method

Resection type

Hydropreparation substances used

Complication after polyp removal?

All polyps removed simultaneously?

Sent for histological examination?

Tumor findings

  • linkId: tumorFindings
  • Answers:

Tumor found?

  • linkId: tumorFindings.tumorFound
  • Answers:

Tumor location

Tumor description

  • linkId: tumorFindings.tumorDescription
  • Answers:

Biopsy performed?

Biopsy postponed?

Complications after colonoscopy

  • linkId: complications
  • Answers:

Were there complications?

Complication type

Wall injury (Sydney classification)

Action taken

Bleeding control details

  • linkId: complications.bleedingControl
  • Enable When: todo
  • Answers:

Final conclusions

  • linkId: conclusions
  • Answers:

Conclusion

Conclusion notes

  • linkId: conclusions.conclusionNotes
  • Answers:

Follow-up recommendations

  • linkId: recommendations
  • Answers:

Recommended interval for next colonoscopy

Additional notes

  • linkId: recommendations.additionalNotes
  • Answers:

Signatures

  • linkId: signatures
  • Answers:

Examiner first name*

  • linkId: signatures.examinerName
  • Answers:

Examiner surname*

  • linkId: signatures.examinerSurname
  • Answers:

Examination date*

  • linkId: signatures.examDate
  • Answers:

Language: en

LinkIDDescription & Constraintsdoco
.. basicInfo Value Set:
... basicInfo.postponedColonoscopy Value Set:
... basicInfo.anesthesia Value Set:
Options: 2 options
... basicInfo.videoColonoscope Value Set:
Options: 2 options
... basicInfo.procedureDate Value Set:
... basicInfo.retroflexionRectum Value Set:
Options: 3 options
... basicInfo.previousAbdominalSurgery Value Set:
Options: 2 options
... basicInfo.previousAbdominalSurgeryDetails Enable When: Not done yet
Value Set:
.. bowelPrep Value Set:
... bowelPrep.prepQuality Value Set:
Options: 2 options
... bowelPrep.bbpsRight Value Set:
... bowelPrep.bbpsTransverse Value Set:
... bowelPrep.bbpsLeft Value Set:
... bowelPrep.totalBbps Value Set:
... bowelPrep.dietaryRecommendations Value Set:
Options: 2 options
... bowelPrep.splitDose Value Set:
Options: 2 options
... bowelPrep.prepMethod Value Set:
Options: 2 options
... bowelPrep.lastDoseHoursBeforeProcedure Value Set:
... bowelPrep.writtenInfo Value Set:
Options: 2 options
... bowelPrep.usedPreparations Value Set:
Options: 4 options
.. scopeReach Value Set:
... scopeReach.reachLocation Value Set:
Options: 11 options
.. polypFindings Value Set:
... polypFindings.polypFound Value Set:
... polypFindings.location Value Set:
Options: 10 options
... polypFindings.sizeMm Value Set:
... polypFindings.parisClassification Value Set:
Options: 9 options
... polypFindings.niceClassification Value Set:
Options: 3 options
... polypFindings.predictedHistology Value Set:
Options: 4 options
... polypFindings.locationSide Value Set:
Options: 2 options
... polypFindings.accessDifficulty Value Set:
Options: 2 options
... polypFindings.smsaScore Value Set:
... polypFindings.smsaLevel Value Set:
Options: 4 options
... polypFindings.polypRemoved Value Set:
Options: 2 options
... polypFindings.removalMethod Enable When: Not done yet
Value Set:
Options: 6 options
... polypFindings.lumenFilling Enable When: Not done yet
Value Set:
Options: 3 options
... polypFindings.resectionType Enable When: Not done yet
Value Set:
Options: 2 options
... polypFindings.hydropreparation Enable When: Not done yet
Value Set:
Options: 4 options
... polypFindings.complicationAfterRemoval Value Set:
Options: 2 options
... polypFindings.allPolypsRemovedSimultaneously Value Set:
Options: 2 options
... polypFindings.sentForHistology Value Set:
Options: 2 options
.. tumorFindings Value Set:
... tumorFindings.tumorFound Value Set:
... tumorFindings.tumorLocation Value Set:
Options: 10 options
... tumorFindings.tumorDescription Value Set:
... tumorFindings.biopsyPerformed Value Set:
Options: 2 options
... tumorFindings.biopsyPostponed Value Set:
Options: 2 options
.. complications Value Set:
... complications.complicationPresence Value Set:
Options: 2 options
... complications.complicationType Enable When: Not done yet
Value Set:
Options: 5 options
... complications.wallInjury Enable When: Not done yet
Value Set:
Options: 5 options
... complications.actionTaken Enable When: Not done yet
Value Set:
Options: 3 options
... complications.bleedingControl Enable When: Not done yet
Value Set:
.. conclusions Value Set:
... conclusions.conclusion Value Set:
Options: 7 options
... conclusions.conclusionNotes Value Set:
.. recommendations Value Set:
... recommendations.nextColonoscopy Value Set:
Options: 5 options
... recommendations.additionalNotes Value Set:
.. signatures Value Set:
... signatures.examinerName Value Set:
... signatures.examinerSurname Value Set:
... signatures.examDate Value Set:

doco Documentation for this format

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