HIS

1 forms

StudyEvent: HIS
1. HIS

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

Administrative Information

Item Group

Administrative Information

C3845829 (UMLS CUI-1)

Aufnahmedatum

Item

Aufnahmedatum

date

Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)

PatientenID

Item

Patientenidentifikationsnummer

integer

Patients (Code-1)
C0030705 (UMLS CUI-1)
116154003 (SNOMED CT-1)
Identification number (Code-2)
C1300638 (UMLS CUI-2)
396278008 (SNOMED CT-2)

Geschlecht

Item

Geschlecht Patient

string

C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)

Nachname

Item

Patienten-Nachname

string

C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)

Vorname

Item

Patienten-Vorname

string

C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)

Geburtsdatum

Item

Patienten-Geburtsdatum

date

C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)

Aufnahmezeit

Item

Aufnahmezeit

date

Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
Hour (Code-2)
C0439227 (UMLS CUI-2)
258702006 (SNOMED CT-2)
HR (HL7 V3-2)

E-Arzt

Item

Einweisender Arzt

string

Admission (Code-1)
C0809949 (UMLS CUI-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
PHYS (HL7 V3-2)

Patienteninformation

Item Group

Patienteninformation

C1955348 (UMLS CUI-1)

Item

Datum

date

Visit Date (Code-1)
C1320303 (UMLS CUI-1)
406543005 (SNOMED CT-1)

durch Dr.

Item

verantwortliche Person

string

Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)

Histologie

Item

Histologie

string

Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)

geplante Operation

Item Group

Operation

Item

Excisionsbiopsie

boolean

changed_datatype (Code-Info)
Excisional Biopsy (Code-1)
C0184921 (UMLS CUI-1)
8889005 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)

BET

Item

Brusterhaltende Therapie

boolean

changed_datatype (Code-Info)
Breast Conservation Treatment (Code-1)
C0917927 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)

onkopl. BET

Item

rekonstruktive brusterhaltende Therapie

boolean

changed_datatype (Code-Info)
Plastic Surgical Procedures (Code-1)
C0677616 (UMLS CUI-1)
286553006 (SNOMED CT-1)
10062082 (MedDRA-1)
Breast Conservation Treatment (Code-2)
C0917927 (UMLS CUI-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)

Item

Mastektomie

boolean

changed_datatype (Code-Info)
Mastectomy (Code-1)
C0024881 (UMLS CUI-1)
10026878 (MedDRA-1)
85.4 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)

geplante Operation II

Item

Operation

integer

C0543467 (UMLS CUI-1)
387713003 (SNOMED CT-1)
10042609 (MedDRA-1)
MTHU007597 (LOINC-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)

SLN

Item

Sentinel Lymphknoten Biopsie

boolean

changed_datatype (Code-Info)
Sentinel Lymph Node Biopsy (Code-1)
C0796693 (UMLS CUI-1)
396487001 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)

aLNE

Item

Axilladissektion

boolean

changed_datatype (Code-Info)
Axillary Lymph Node Dissection (Code-1)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)

Rekonstruktion gewünscht

Item

Rekonstruktion

integer

Reconstructive Surgical Procedures (Code-1)
C0524865 (UMLS CUI-1)
122465003 (SNOMED CT-1)
MTHU010401 (LOINC-1)

Rekonstruktion gewünscht

Code List

Rekonstruktion

CL Item

nicht notwendig (nicht notwendig)

Requirement (Code-1)
C1514873 (UMLS CUI-1)
Negation (Code-2)
C1518422 (UMLS CUI-2)

CL Item

Nein (nein, aber Aufklärung erfolgt)

No (Code-1)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)

CL Item

Ja (ja)

Yes (Code-1)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)

CL Item

Expander (Implantat/Expander)

Insertion of breast tissue expander (Code-1)
C0177682 (UMLS CUI-1)
85.95 (ICD-9-CM-1)

CL Item

Latissimus dorsi Muskel-Unterhaut-Lappen (Lat. Dorsi)

Reconstruction of breast using myocutaneous flap of latissimus dorsi muscle (procedure) (Code-1)
C0405407 (UMLS CUI-1)
172057008 (SNOMED CT-1)

CL Item

Transverser Rectus Abdominis Musculocutaneus-Lappen (TRAM)

extended_coding (Code-Info)
Breast reconstruction with TRAM flap (procedure) (Code-1)
C0521240 (UMLS CUI-1)
70966003 (SNOMED CT-1)
10044333 (MedDRA-1)

CL Item

Tiefer inferiorer epigastrischer Perforatorlappen (DIEP)

extended_coding (Code-Info)
DIEP Flap (Code-1)
C2985549 (UMLS CUI-1)

stationäre Aufnahme am

Item

Aufnahmedatum

date

Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)

verantwortlicher Operateur

Item

erster Operateur

string

primary surgeon (Code-1)
C0808118 (UMLS CUI-1)
MTHU010488 (LOINC-1)
PRISURG (HL7 V3-1)

Patienteninformation II

Item Group

Patienteninformation II

C1955348 (UMLS CUI-1)

Intention

Item

Intent Chemotherapie

text

normalized_coding (Code-Info)
Intention (Code-1)
367565008 (SNOMED CT-1)
Chemotherapy Regimen (Code-2)
69960004 (SNOMED CT-2)
10061758 (MedDRA-2)
Plan (Code-3)
397943006 (SNOMED CT-3)
C1283828 (UMLS CUI-1)
C0392920 (UMLS CUI-2)
C1301732 (UMLS CUI-3)

Intention

Code List

Intent Chemotherapie

CL Item

(N)

C1298676 (UMLS CUI-1)

Studie

Item

klinische Studie

string

C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)

Staging

Item

Staging

integer

disease stage (Code-1)
C0699749 (UMLS CUI-1)

Staging

Code List

Staging

CL Item

präoperativ (präoperativ)

Preoperative (Code-1)
C0445204 (UMLS CUI-1)
262068006 (SNOMED CT-1)

CL Item

postoperativ (postoperativ)

Postoperative (Code-1)
C0032790 (UMLS CUI-1)
262061000 (SNOMED CT-1)

Rö-Thorax

Item

Röntgen Thorax

boolean

Radiographic imaging procedure (Code-1)
C1962945 (UMLS CUI-1)
363680008 (SNOMED CT-1)
10048064 (MedDRA-1)
Thorax (Code-2)
C0817096 (UMLS CUI-2)
51185008 (SNOMED CT-2)

Rö-Thorax

Item

Datum Röntgen Thorax

date

Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)

Befund Rö-Thorax

Item

Befund Röntgen Thorax - Freitext

string

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)

Befund II Rö-Thorax

Item

Befund Röntgen Thorax

integer

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)

Befund II Rö-Thorax

Code List

Befund Röntgen Thorax

CL Item

unauffällig (unauffällig)

Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)

CL Item

auffällig (auffällig)

Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)

OB-Sono

Item

Sonographie Abdomen

boolean

Ultrasonography (Code-1)
C0041618 (UMLS CUI-1)
16310003 (SNOMED CT-1)
10045434 (MedDRA-1)
MTHU000076 (LOINC-1)
12 (CTCAE-1)
Abdomen (Code-2)
C0000726 (UMLS CUI-2)
113345001 (SNOMED CT-2)
MTHU001425 (LOINC-2)

OB-Sono

Item

Datum Sonographie Abdomen

date

Ultrasonography (Code-1)
C0041618 (UMLS CUI-1)
16310003 (SNOMED CT-1)
10045434 (MedDRA-1)
MTHU000076 (LOINC-1)

Befund OB-Sono

Item

Befund Sonographie Abdomen - Freitext

string

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Ultrasonography (Code-2)
C0041618 (UMLS CUI-2)
16310003 (SNOMED CT-2)
10045434 (MedDRA-2)
MTHU000076 (LOINC-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)

Befund II OB-Sono

Item

Befund Sonographie Abdomen

integer

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Ultrasonography (Code-2)
C0041618 (UMLS CUI-2)
16310003 (SNOMED CT-2)
10045434 (MedDRA-2)
MTHU000076 (LOINC-2)

Befund II OB-Sono

Code List

Befund Sonographie Abdomen

CL Item

unauffällig (unauffällig)

Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)

CL Item

auffällig (auffällig)

Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)

Skelett-Szinitigr.

Item

Szinitgraphie

boolean

Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)

Skelett-Szinitigr.

Item

Datum Szintigraphie

date

Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)

Befund Skelett-Szinitigr.

Item

Befund Szintigraphie - Freitext

string

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radionuclide Imaging (Code-2)
C0034606 (UMLS CUI-2)
399019003 (SNOMED CT-2)
10061478 (MedDRA-2)
92 (ICD-9-CM-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)

Befund II Skelett-Szinitigr.

Item

Befund Szintigraphie

integer

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radionuclide Imaging (Code-2)
C0034606 (UMLS CUI-2)
399019003 (SNOMED CT-2)
10061478 (MedDRA-2)
92 (ICD-9-CM-2)

Befund II Skelett-Szinitigr.

Code List

Befund Szintigraphie

CL Item

unauffällig (unauffällig)

Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)

CL Item

auffällig (auffällig)

Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)

Computertomogr.

Item

Computertomographie

boolean

X-Ray Computed Tomography (Code-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)

Computertomogr.

Item

Datum Computertomographie

date

X-Ray Computed Tomography (Code-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)

Befund Computertomogr.

Item

Befund Computertomographie - Freitext

string

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
X-Ray Computed Tomography (Code-2)
C0040405 (UMLS CUI-2)
77477000 (SNOMED CT-2)
10010234 (MedDRA-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)

Befund II Computertomogr.

Item

Befund Computertomographie

integer

Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
X-Ray Computed Tomography (Code-2)
C0040405 (UMLS CUI-2)
77477000 (SNOMED CT-2)
10010234 (MedDRA-2)

Befund II Computertomogr.

Code List

Befund Computertomographie

CL Item

unauffällig (unauffällig)

Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)

CL Item

auffällig (auffällig)

Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)

Metastasen (M1)

Item

Fernmetastasen

string

Distant Metastasis (Code-1)
CL278860 (UMLS CUI-1)

Patientin wünscht Zweitmeinung

Item

Zweitmeinung erwünscht

boolean

Second Opinion (Code-1)
C0036524 (UMLS CUI-1)
desire (Code-2)
C0871633 (UMLS CUI-2)

Ort Zweitmeinung

Item

Ort Zweitmeinung

string

Second Opinion (Code-1)
C0036524 (UMLS CUI-1)
Place (Code-2)
C0442504 (UMLS CUI-2)
257557008 (SNOMED CT-2)

Unterschrift

Item

Unterschrift

string

Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)

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