ID

21769

Description

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: CA_AHB-Befundbericht

Keywords

Versions (1)
  1. 4/29/17 4/29/17 -
Uploaded on

April 29, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Cancer follow-up treatment form, University Hospital Cologne

German English

Cancer follow-up treatment form, University Hospital Cologne

1 forms  
AHB Befundbericht für Tumorpatienten
Description

AHB Befundbericht für Tumorpatienten

Alias
UMLS CUI-1
C0683527
UMLS CUI-2
C0034991
UMLS CUI-3
C0006826
Patient
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Geschlecht
Description

Gender

Data type

integer

Alias
UMLS CUI [1]
C0079399
Geburtsdatum
Description

Birth Date

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1]
C0421451
dd.mm.yyyy
Adresse des Patienten
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Kostenträger
Description

Healthcare payer

Data type

text

Alias
UMLS CUI [1,1]
C2348942
UMLS CUI [1,2]
C0021682
Diagnose und Lokalisation der malignen Erkrankung
Description

Diagnosis and localization of malignant disease

Data type

text

Alias
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C2598420
UMLS CUI [2]
C3897292
pT pathologische Klassifikation
Description

pT Staging

Data type

text

Alias
UMLS CUI [1]
C1272834
pN Pathologische Klassifikation
Description

pN Staging

Data type

text

Alias
UMLS CUI [1]
C1272833
pM Pathologische Klassifikation
Description

pM Staging

Data type

text

Alias
UMLS CUI [1]
C1272832
Histopathologisches Grading
Description

Histopathologic Grade

Data type

integer

Alias
UMLS CUI [1]
C0919553
Histomorphologischer Befund
Description

Hiistomorphologic finding

Data type

text

Alias
UMLS CUI [1,1]
C1516204
UMLS CUI [1,2]
C0243095
Seit wann ist die Krankheit bekannt? (Erstdiagnose Monat/Jahr)
Description

Date of diagnosis

Data type

date

Measurement units
  • mm/yyyy
Alias
UMLS CUI [1]
C2316983
mm/yyyy
Hormonrezeptor bestimmt?
Description

Hormone receptor finding

Data type

boolean

Alias
UMLS CUI [1,1]
C0019929
UMLS CUI [1,2]
C0430022
Tumormarker (Bezeichnung, Wert, Datum)
Description

Tumor markers

Data type

text

Alias
UMLS CUI [1]
C0041365
Operationen?
Description

Surgical procedures

Data type

boolean

Alias
UMLS CUI [1]
C0543467
Strahlentherapie?
Description

Radiotherapy

Data type

boolean

Alias
UMLS CUI [1]
C1522449
Zytostatische / hormonelle Behandlung?
Description

Cytostatic or hormone therapy

Data type

boolean

Alias
UMLS CUI [1]
C2609342
UMLS CUI [2]
C0279025
Unspezifische medikamentöse Dauerbehandlung im Zusammenhang mit der malignen Erkrankung?
Description

Other treatment for malignant disease

Data type

boolean

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0087111
UMLS CUI [1,3]
C0006826
Eingehender Allgemeinbefund
Description

Eingehender Allgemeinbefund

Alias
UMLS CUI-1
C0031809
UMLS CUI-2
C0243095
Körperlicher Untersuchungsbefund
Description

Physical examination finding

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0243095
Körpergröße
Description

Body Height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Körpergewicht
Description

Body Weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Puls
Description

Heart rate

Data type

integer

Measurement units
  • /min
Alias
UMLS CUI [1]
C0018810
/min
Blutdruck
Description

Blood Pressure

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0005823
mmHg
Diagnosen der Begleiterkrankungen
Description

Diagnosen der Begleiterkrankungen

Alias
UMLS CUI-1
C0009488
Anus praeter
Description

Preternatural anus

Data type

boolean

Alias
UMLS CUI [1]
C1611169
Harninkontinenz
Description

Urinary incontinence

Data type

boolean

Alias
UMLS CUI [1]
C0042024
Bein-/Armamputation
Description

Amputation of leg or arm

Data type

boolean

Alias
UMLS CUI [1]
C0337308
UMLS CUI [2]
C0186399
Hochgradige Sehschwäche/Blindheit
Description

Severe visual impairment or blindness

Data type

boolean

Alias
UMLS CUI [1,1]
C0205082
UMLS CUI [1,2]
C3665347
UMLS CUI [2]
C0456909
Tracheostoma
Description

Tracheostoma

Data type

boolean

Alias
UMLS CUI [1]
C0260682
Stuhlinkontinenz
Description

Fecal incontinence

Data type

boolean

Alias
UMLS CUI [1]
C0015732
Diabetes
Description

Diabetes

Data type

boolean

Alias
UMLS CUI [1]
C0011849
Dauerkatheter
Description

Urinary catheter

Data type

boolean

Alias
UMLS CUI [1]
C0179802
Lymphödem
Description

Lymphedema

Data type

boolean

Alias
UMLS CUI [1]
C0024236
Medikamentenallergie
Description

Drug allergy

Data type

boolean

Alias
UMLS CUI [1]
C0013182
Suchtproblematik
Description

Substance use disorder

Data type

boolean

Alias
UMLS CUI [1]
C0038586
Karnofsky Index
Description

Karnofsky performance score

Data type

integer

Measurement units
  • %
Alias
UMLS CUI [1]
C0206065
%
Kann der Patient ohne Hilfe essen?
Description

Help with eating

Data type

boolean

Alias
UMLS CUI [1,1]
C3641746
UMLS CUI [1,2]
C0558129
Kann der Patient sich alleine waschen und anziehen?
Description

Help with washing or dressing

Data type

boolean

Alias
UMLS CUI [1,1]
C3641746
UMLS CUI [1,2]
C0564675
UMLS CUI [1,3]
C0518459
Kann der Patient sich alleine auf Station bewegen?
Description

Mobility on ward

Data type

boolean

Alias
UMLS CUI [1]
C0449580
Ist der / die Betreute allein mit öffentl. Verkehrsmitteln reisefähig?
Description

Ability to use public transportation

Data type

boolean

Alias
UMLS CUI [1]
C0577341
Begleitung für Anreise zur AHB erforderlich?
Description

Assitance with journey to follow-up treatment facility

Data type

boolean

Alias
UMLS CUI [1,1]
C1822191
UMLS CUI [1,2]
C0683527
UMLS CUI [1,3]
C0034991
PKW Transport erforderlich?
Description

Transport by car

Data type

boolean

Alias
UMLS CUI [1,1]
C1547285
UMLS CUI [1,2]
C0034991
Krankenwagen erforderlich?
Description

Ambulance transport

Data type

boolean

Alias
UMLS CUI [1]
C1547284
Datum
Description

Date of report

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1]
C1302584
dd.mm.yyyy
Unterschrift Arzt
Description

Signature physician

Data type

text

Alias
UMLS CUI [1]
C0807938
Fachabteilung und Station
Description

Medical specialty and ward

Data type

text

Alias
UMLS CUI [1,1]
C0037778
UMLS CUI [1,2]
C1305702
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Similar models

Cancer follow-up treatment form, University Hospital Cologne

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
AHB Befundbericht für Tumorpatienten
C0683527 (UMLS CUI-1)
C0034991 (UMLS CUI-2)
C0006826 (UMLS CUI-3)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Item
Geschlecht
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Geschlecht
CL Item
männlich (1)
CL Item
weiblich (2)
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Patient address
Item
Adresse des Patienten
text
C0421449 (UMLS CUI [1])
Healthcare payer
Item
Kostenträger
text
C2348942 (UMLS CUI [1,1])
C0021682 (UMLS CUI [1,2])
Diagnosis and localization of malignant disease
Item
Diagnose und Lokalisation der malignen Erkrankung
text
C0006826 (UMLS CUI [1,1])
C2598420 (UMLS CUI [1,2])
C3897292 (UMLS CUI [2])
pT Staging
Item
pT pathologische Klassifikation
text
C1272834 (UMLS CUI [1])
pN Staging
Item
pN Pathologische Klassifikation
text
C1272833 (UMLS CUI [1])
pM Staging
Item
pM Pathologische Klassifikation
text
C1272832 (UMLS CUI [1])
Item
Histopathologisches Grading
integer
C0919553 (UMLS CUI [1])
Histopathologic Grade
Code List
Histopathologisches Grading
CL Item
G1 (1)
CL Item
G2 (2)
CL Item
G3 (3)
CL Item
G4 (4)
Hiistomorphologic finding
Item
Histomorphologischer Befund
text
C1516204 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Date of diagnosis
Item
Seit wann ist die Krankheit bekannt? (Erstdiagnose Monat/Jahr)
date
C2316983 (UMLS CUI [1])
Hormone receptor finding
Item
Hormonrezeptor bestimmt?
boolean
C0019929 (UMLS CUI [1,1])
C0430022 (UMLS CUI [1,2])
Tumor markers
Item
Tumormarker (Bezeichnung, Wert, Datum)
text
C0041365 (UMLS CUI [1])
Surgical procedures
Item
Operationen?
boolean
C0543467 (UMLS CUI [1])
Radiotherapy
Item
Strahlentherapie?
boolean
C1522449 (UMLS CUI [1])
Cytostatic or hormone therapy
Item
Zytostatische / hormonelle Behandlung?
boolean
C2609342 (UMLS CUI [1])
C0279025 (UMLS CUI [2])
Other treatment for malignant disease
Item
Unspezifische medikamentöse Dauerbehandlung im Zusammenhang mit der malignen Erkrankung?
boolean
C0205394 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C0006826 (UMLS CUI [1,3])
Item Group
Eingehender Allgemeinbefund
C0031809 (UMLS CUI-1)
C0243095 (UMLS CUI-2)
Physical examination finding
Item
Körperlicher Untersuchungsbefund
text
C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Body Height
Item
Körpergröße
integer
C0005890 (UMLS CUI [1])
Body Weight
Item
Körpergewicht
float
C0005910 (UMLS CUI [1])
Heart rate
Item
Puls
integer
C0018810 (UMLS CUI [1])
Blood Pressure
Item
Blutdruck
integer
C0005823 (UMLS CUI [1])
Item Group
Diagnosen der Begleiterkrankungen
C0009488 (UMLS CUI-1)
Preternatural anus
Item
Anus praeter
boolean
C1611169 (UMLS CUI [1])
Urinary incontinence
Item
Harninkontinenz
boolean
C0042024 (UMLS CUI [1])
Amputation of leg or arm
Item
Bein-/Armamputation
boolean
C0337308 (UMLS CUI [1])
C0186399 (UMLS CUI [2])
Severe visual impairment or blindness
Item
Hochgradige Sehschwäche/Blindheit
boolean
C0205082 (UMLS CUI [1,1])
C3665347 (UMLS CUI [1,2])
C0456909 (UMLS CUI [2])
Tracheostoma
Item
Tracheostoma
boolean
C0260682 (UMLS CUI [1])
Fecal incontinence
Item
Stuhlinkontinenz
boolean
C0015732 (UMLS CUI [1])
Diabetes
Item
Diabetes
boolean
C0011849 (UMLS CUI [1])
Urinary catheter
Item
Dauerkatheter
boolean
C0179802 (UMLS CUI [1])
Lymphedema
Item
Lymphödem
boolean
C0024236 (UMLS CUI [1])
Drug allergy
Item
Medikamentenallergie
boolean
C0013182 (UMLS CUI [1])
Substance use disorder
Item
Suchtproblematik
boolean
C0038586 (UMLS CUI [1])
Karnofsky performance score
Item
Karnofsky Index
integer
C0206065 (UMLS CUI [1])
Help with eating
Item
Kann der Patient ohne Hilfe essen?
boolean
C3641746 (UMLS CUI [1,1])
C0558129 (UMLS CUI [1,2])
Help with washing or dressing
Item
Kann der Patient sich alleine waschen und anziehen?
boolean
C3641746 (UMLS CUI [1,1])
C0564675 (UMLS CUI [1,2])
C0518459 (UMLS CUI [1,3])
Mobility on ward
Item
Kann der Patient sich alleine auf Station bewegen?
boolean
C0449580 (UMLS CUI [1])
Ability to use public transportation
Item
Ist der / die Betreute allein mit öffentl. Verkehrsmitteln reisefähig?
boolean
C0577341 (UMLS CUI [1])
Assitance with journey to follow-up treatment facility
Item
Begleitung für Anreise zur AHB erforderlich?
boolean
C1822191 (UMLS CUI [1,1])
C0683527 (UMLS CUI [1,2])
C0034991 (UMLS CUI [1,3])
Transport by car
Item
PKW Transport erforderlich?
boolean
C1547285 (UMLS CUI [1,1])
C0034991 (UMLS CUI [1,2])
Ambulance transport
Item
Krankenwagen erforderlich?
boolean
C1547284 (UMLS CUI [1])
Date of report
Item
Datum
date
C1302584 (UMLS CUI [1])
Signature physician
Item
Unterschrift Arzt
text
C0807938 (UMLS CUI [1])
Medical specialty and ward
Item
Fachabteilung und Station
text
C0037778 (UMLS CUI [1,1])
C1305702 (UMLS CUI [1,2])
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