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ID
10222
Beschreibung
documentation standard - breast cancer - gynecology, with friendly permission (Dr. Tio) - kooperatives Brustzentrum Münster, Bereich Senologie an der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe - Leitung: Dr. med. Joke Tio
Stichworte
Versionen (3)
- 07.08.13 07.08.13 -
- 17.05.15 17.05.15 - Martin Dugas
- 27.09.21 27.09.21 -
Hochgeladen am
17. Mai 2015
DOI
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Lizenz
Creative Commons BY-NC 3.0 Legacy
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documentation standard - breast cancer - talk after biopsy
Ähnliche Modelle
HIS
- StudyEvent: HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Aufnahmedatum
Item
Aufnahmedatum
date
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)
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)
184100006 (SNOMED CT-1)
Nachname
Item
Patienten-Nachname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patienten-Vorname
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
184095009 (SNOMED CT-1)
Geburtsdatum
Item
Patienten-Geburtsdatum
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-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)
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)
C0809949 (UMLS CUI-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
PHYS (HL7 V3-2)
am
Item
Datum
date
Visit Date (Code-1)
C1320303 (UMLS CUI-1)
406543005 (SNOMED CT-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)
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)
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)
DE
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)
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)
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)
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)
ME
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)
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)
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)
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)
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)
Item
Rekonstruktion
integer
Reconstructive Surgical Procedures (Code-1)
C0524865 (UMLS CUI-1)
122465003 (SNOMED CT-1)
MTHU010401 (LOINC-1)
C0524865 (UMLS CUI-1)
122465003 (SNOMED CT-1)
MTHU010401 (LOINC-1)
CL Item
nicht notwendig (nicht notwendig)
Requirement (Code-1)
C1514873 (UMLS CUI-1)
Negation (Code-2)
C1518422 (UMLS CUI-2)
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)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Ja (ja)
Yes (Code-1)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-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)
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)
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)
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)
DIEP Flap (Code-1)
C2985549 (UMLS CUI-1)
stationäre Aufnahme am
Item
Aufnahmedatum
date
verantwortlicher Operateur
Item
erster Operateur
string
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-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)
CL Item
(N)
C1298676 (UMLS CUI-1)
Studie
Item
klinische Studie
string
C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)
110465008 (SNOMED CT-1)
CL Item
präoperativ (präoperativ)
Preoperative (Code-1)
C0445204 (UMLS CUI-1)
262068006 (SNOMED CT-1)
C0445204 (UMLS CUI-1)
262068006 (SNOMED CT-1)
CL Item
postoperativ (postoperativ)
Postoperative (Code-1)
C0032790 (UMLS CUI-1)
262061000 (SNOMED CT-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)
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)
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)
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)
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)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-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)
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)
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)
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)
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)
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)
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-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)
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)
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)
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)
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)
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)
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-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)
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)
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)
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)
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)
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)
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Metastasen (M1)
Item
Fernmetastasen
string
Distant Metastasis (Code-1)
CL278860 (UMLS CUI-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)
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)
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)
C0807938 (UMLS CUI-1)