| Source | hl7.fhir.uv.ichom-breast-cancer#current:ICHOM Patient Centered Outcomes Measure Set for Breast Cancer (v4.0.1) |
| resourceType | Questionnaire |
| id | ClinicalResponseSixMonths |
| canonical | http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/ClinicalResponseSixMonths |
| version | 1.0.0 |
| status | draft |
| publisher | HL7 International - Clinical Interoperability Council Group |
| name | ClinicalResponseSixMonths |
| title | Clinical response at 6 months post-treatment follow-up |
| date | 2023-08-18T15:07:30+00:00 |
| experimental | true |
| description | Clinical response questionnaire at 6 months 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*
Has the patient received surgery? *
Indicate the pathological tumor stage (per AJCC 8th Ed.) *
Indicate the pathological nodal stage (per AJCC 8th Ed.) *
Indicate the pathological distant metastasis (per AJCC 8th Ed.) *
Indicate size of invasive component of tumor (in mm) *
Indicate the number of lymph nodes resected *
Indicate the number of lymph nodes involved according to the TNM stage AJCC 8th Ed. *
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 *
Disutility of care*
Indicate if the patient has undergone a reoperation due to involved margins after primary surgery *
What type of reconstruction did the patient receive during reoperation? *
Is the date of the reoperation due to positive margins known? *
Provide the date of the reoperation due to positive margins *
What was the impact of the complication experienced by the patient *
Indicate whether the complication is attributable to treatment *
Indicate the type of complication *
Produced 08 Sep 2023