| Source | hl7.fhir.uv.ichom-breast-cancer#current:ICHOM Patient Centered Outcomes Measure Set for Breast Cancer (v4.0.1) |
| resourceType | Questionnaire |
| id | ClinicalResponseAnnualUpdate |
| canonical | http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/ClinicalResponseAnnualUpdate |
| version | 1.0.0 |
| status | draft |
| publisher | HL7 International - Clinical Interoperability Council Group |
| name | AnnualClinicalResponse |
| title | Annual follow-up of clinical questionnaire response |
| date | 2023-08-18T15:07:30+00:00 |
| experimental | true |
| description | Clinical response questionnaire at annual post-treatment follow-up |
| jurisdictions | uv |
| Usages | (none) |
General information*
What is the patient's medical record number? *
What is the patient's last name? *
Tumor factors*
Indicate if the patient carries a genetic mutation predisposing breast cancer *
Treatment Variables*
Indicate whether the patient received one of the following treatment during the last year (select all that apply) *
Indicate whether the patient received surgery during the last year *
Is the date of surgery known? *
Please provide the date of surgery *
Indicate whether the patient received surgery to the axilla *
Is the date of surgery to the axilla known? *
Please provide the date of surgery to the axilla *
Indicate whether the patient received axillary clearance due to lymph node involvement after sentinel lymph node biopsy during the last year *
Is the date of axillary clearance known? *
Please provide the date of axillary clearance *
Indicate whether the patient received a delayed reconstruction *
Indicate what type of reconstruction the patient received *
Indicate the location of the implant *
Is the date of the delayed reconstruction known? *
Please provide the date of delayed reconstruction *
What was the intent of radiotherapy *
Indicate location/type of radiotherapy *
Is the start date of radiotherapy known? *
Please provide the start date of radiotherapy *
Is the stop date of radiotherapy known? *
Please provide the stop date of radiotherapy *
Indicate the intent of chemotherapy *
Indicate the type of chemotherapy (select all that apply) *
Is the start date of chemotherapy known? *
Please provide the start date of chemotherapy *
Is the stop date of chemotherapy known? *
Please provide the stop date of chemotherapy *
Indicate the intent of hormonal therapy *
Indicate the type of hormonal therapy (select all that apply) *
Is the start date of hormonal therapy known? *
Please provide the start date of hormonal therapy *
Is the stop date of hormonal therapy known? *
Please provide the stop date of hormonal therapy, if applicable *
Indicate the type of targeted therapy *
Is the start date of targeted therapy known? *
Please provide the start date of targeted therapy *
Is the stop date of targeted therapy known? *
Please provide the stop date of targeted therapy *
Indicate if the patient has had one of the following re-operations since their surgery for breast cancer (select all that apply) *
Is the date of the reoperation known? *
Please provide the date of the reoperation *
Survival and disease control*
Was the intent of the treatment curative? *
Is there evidence of local, regional or distant recurrence of neoplasm? *
What was the method of confirming recurrence of neoplasm? *
Is the date of cancer recurrence known? *
What is the date of cancer recurrence? *
Indicate if the person has deceased, regardless of cause *
Is the date of death of the patient known? *
Please provide the date of death of the patient *
Is the death attributable to breast cancer? *
Produced 08 Sep 2023