ID

4106

Beschreibung

HIS form from Soarian. Urologie Erlangen" with friendly permission of the urology Erlangen (Prof. Wullich) and the medical informatics department Erlangen (PD Dr. Bürkle)

Stichworte

Versionen (1)
  1. 07.08.13 07.08.13 -
Hochgeladen am

7. August 2013

DOI

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HIS pathology report - biopsy prostate cancer

Deutsch Englisch

HIS

1 Formulare  
  1. StudyEvent: HIS
    1. HIS
Admininstrative Daten
Beschreibung

Admininstrative Daten

Patient surname
Beschreibung

Name

Datentyp

string

Alias
UMLS CUI-1
C0421448
SNOMED CT-1
184096005
Patient forename
Beschreibung

Vorname

Datentyp

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patient title
Beschreibung

Titel

Datentyp

string

Alias
Code-1
Patient title (observable entity)
UMLS CUI-1
C0421450
SNOMED CT-1
184098006
former Patient name
Beschreibung

früherer Name

Datentyp

string

Alias
Code-1
Previous
UMLS CUI-1
C0205156
SNOMED CT-1
9130008
Code-2
Patient name (observable entity)
UMLS CUI-2
C1299487
SNOMED CT-2
371484003
Patient date of birth
Beschreibung

Geburtsdatum

Datentyp

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
patient age
Beschreibung

Alter

Datentyp

integer

Alias
Code-1
patient age
UMLS CUI-1
CL386174
Ethnicity / related nationality data
Beschreibung

Nationalität

Datentyp

string

Alias
UMLS CUI-1
C0438960
SNOMED CT-1
186034007
Code-2
Patients
UMLS CUI-2
C0030705
SNOMED CT-2
116154003
Street Address
Beschreibung

Adresse

Datentyp

string

Alias
UMLS CUI-1
C1301826
SNOMED CT-1
398099009
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
Patient postal code
Beschreibung

PLZ

Datentyp

integer

Alias
UMLS CUI-1
C0421454
SNOMED CT-1
184102003
City of residence
Beschreibung

Stadt

Datentyp

string

Alias
UMLS CUI-1
C2316883
SNOMED CT-1
433178008
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
Case Identifier
Beschreibung

Fallnummer

Datentyp

integer

Alias
Code-1
Case - situation (qualifier value)
UMLS CUI-1
C0868928
SNOMED CT-1
398241000
Code-2
Identifier
UMLS CUI-2
C0600091
SNOMED CT-2
118522005
Tumorhistologie
Beschreibung

Tumorhistologie

General pathology department
Beschreibung

Pathologisches Institut

Datentyp

string

Alias
UMLS CUI-1
C0587490
SNOMED CT-1
309953001
Histopathology-number
Beschreibung

Histologie-Einsendenummer

Datentyp

string

Alias
Item-Info
must_have
Code-1
Histopathology
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Nummer/Identifier
UMLS CUI-2
C0600091
SNOMED CT-2
118522005
LOINC-2
MTHU003116
Admission Information
Beschreibung

Aufnahme-Nr. WHK

Datentyp

string

Alias
Code-1
Admission Information
UMLS CUI-1
C2599639
Histopathology
Beschreibung

Histopathology

Date of Histology
Beschreibung

Histologie-Datum

Datentyp

date

Alias
Item-Info
must_have
Code-1
Date of pathology report (observable entity)
UMLS CUI-1
C1302659
SNOMED CT-1
399737008
Time of entry
Beschreibung

Eingangszeit

Datentyp

string

Alias
Code-1
Date of entry
UMLS CUI-1
C1978797
LOINC-1
MTHU026971
Histology ICD-O-3
Beschreibung

Histologie ICD-0-3

Datentyp

string

Alias
Item-Info
must_have
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Histopathology
Beschreibung

sonstige Histologie

Datentyp

string

Alias
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
Code-3
Biopsy
UMLS CUI-3
C0005558
SNOMED CT-3
86273004
MedDRA-3
10004720
LOINC-3
MTHU028106
Histology ICD-O-3
Beschreibung

mit ICD-0-3

Datentyp

string

Alias
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
Code-3
Biopsy
UMLS CUI-3
C0005558
SNOMED CT-3
86273004
MedDRA-3
10004720
LOINC-3
MTHU028106
Stanzen
Beschreibung

Stanzen

Biopsy Site
Beschreibung

Ort der Stanze

Datentyp

integer

Alias
UMLS CUI-1
C1301128
SNOMED CT-1
396991001
Stanze
Beschreibung

Stanze

Biopsy
Beschreibung

Stanze

Datentyp

integer

Alias
Code-Info
for_compare
Code-1
Biopsy
UMLS CUI-1
C0005558
SNOMED CT-1
86273004
MedDRA-1
10004720
LOINC-1
MTHU028106
executed
Beschreibung

durchgeführt

Datentyp

integer

Alias
Code-Info
changed_datatype
Code-1
Execution
UMLS CUI-1
C1705848
No tumor present in specimen
Beschreibung

kein Tumornachweis

Datentyp

boolean

Alias
Code-1
No tumor present in specimen (finding)
UMLS CUI-1
C1300994
SNOMED CT-1
396796000
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Total Gleason Score for Prostate Cancer
Beschreibung

Gleason-Summe

Datentyp

integer

Alias
UMLS CUI-1
C1273607
SNOMED CT-1
384997002
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Primary Gleason Pattern
Beschreibung

Gleason-1

Datentyp

integer

Alias
UMLS CUI-1
C1273604
SNOMED CT-1
384994009
LOINC-1
MTHU020049
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Secondary Gleason Pattern
Beschreibung

Gleason-2

Datentyp

integer

Alias
UMLS CUI-1
C1273605
SNOMED CT-1
384995005
LOINC-1
MTHU020050
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma
Beschreibung

Tumor in % der Stanze

Datentyp

string

Alias
Code-1
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma (observable entity)
UMLS CUI-1
C1272841
SNOMED CT-1
385396009
Length of specimen
Beschreibung

Länge (in mm)

Datentyp

string

Alias
Code-1
Length of core in specimen obtained by needle biopsy (observable entity)
UMLS CUI-1
C1302538
SNOMED CT-1
99598003
Other useful information
Beschreibung

sonstige Information

Datentyp

string

Alias
UMLS CUI-1
C2598196
LOINC-1
MTHU029932
Atypical Small Acinar Proliferation of the Prostate Gland
Beschreibung

ASAP

Datentyp

boolean

Alias
UMLS CUI-1
C1332353
High Grade Prostatic Intraepithelial Neoplasia
Beschreibung

PIN-HG

Datentyp

boolean

Alias
UMLS CUI-1
C1168327
SNOMED CT-1
446711009
prostatitis
Beschreibung

Prostatis

Datentyp

boolean

Alias
UMLS CUI-1
C0033581
SNOMED CT-1
9713002
MedDRA-1
10036978
ICD-10-CM-1
N41.9
ICD-9-CM-1
601.9
Necrosis
Beschreibung

Nekrosen

Datentyp

boolean

Alias
UMLS CUI-1
C0027540
SNOMED CT-1
6574001
MedDRA-1
10028851
Seminal vesicle invasion
Beschreibung

Samenblaseninfiltration

Datentyp

boolean

Alias
Code-1
Seminal vesicle invasion by tumor present (finding)
UMLS CUI-1
C1268952
SNOMED CT-1
372294007
extraprostatic extension
Beschreibung

extraprostat. Ausbreitung

Datentyp

boolean

Alias
Code-1
Extraprostatic extension of tumor present (finding)
UMLS CUI-1
C1276734
SNOMED CT-1
372306004
Perineural invasion
Beschreibung

Perineuralscheideninvasion

Datentyp

boolean

Alias
Code-1
Perineural invasion finding
UMLS CUI-1
C1300724
SNOMED CT-1
396394004
TP63 protein
Beschreibung

p63 (negativ)

Datentyp

boolean

Alias
Code-1
TP63 protein, human
UMLS CUI-1
C1431519
Code-2
Negative Finding
UMLS CUI-2
C0205160
SNOMED CT-2
260385009
Alpha-Methylacyl-CoA Racemase
Beschreibung

AMACR (positiv)

Datentyp

boolean

Alias
UMLS CUI-1
C0666209
SNOMED CT-1
130879000
Code-2
Positive Finding
UMLS CUI-2
C1446409
SNOMED CT-2
10828004
Site of distant metastasis
Beschreibung

Site of distant metastasis

Site of distant metastasis
Beschreibung

Lokalisation 1

Datentyp

string

Alias
Code-1
Site of distant metastasis (observable entity)
UMLS CUI-1
C0807944
SNOMED CT-1
385421009
LOINC-1
MTHU010380
Date in time
Beschreibung

Datum

Datentyp

date

Alias
Code-1
Date of diagnosis (observable entity)
UMLS CUI-1
C2316983
SNOMED CT-1
432213005
LOINC-1
MTHU038128
Code-2
Distant Metastasis
UMLS CUI-2
CL278860
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Ähnliche Modelle

HIS

1 Formulare
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Admininstrative Daten
Name
Item
Patient surname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patient forename
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
Titel
Item
Patient title
string
Patient title (observable entity) (Code-1)
C0421450 (UMLS CUI-1)
184098006 (SNOMED CT-1)
früherer Name
Item
former Patient name
string
Previous (Code-1)
C0205156 (UMLS CUI-1)
9130008 (SNOMED CT-1)
Patient name (observable entity) (Code-2)
C1299487 (UMLS CUI-2)
371484003 (SNOMED CT-2)
Geburtsdatum
Item
Patient date of birth
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Alter
Item
patient age
integer
patient age (Code-1)
CL386174 (UMLS CUI-1)
Nationalität
Item
Ethnicity / related nationality data
string
C0438960 (UMLS CUI-1)
186034007 (SNOMED CT-1)
Patients (Code-2)
C0030705 (UMLS CUI-2)
116154003 (SNOMED CT-2)
Adresse
Item
Street Address
string
C1301826 (UMLS CUI-1)
398099009 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
PLZ
Item
Patient postal code
integer
C0421454 (UMLS CUI-1)
184102003 (SNOMED CT-1)
Stadt
Item
City of residence
string
C2316883 (UMLS CUI-1)
433178008 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
Fallnummer
Item
Case Identifier
integer
Case - situation (qualifier value) (Code-1)
C0868928 (UMLS CUI-1)
398241000 (SNOMED CT-1)
Identifier (Code-2)
C0600091 (UMLS CUI-2)
118522005 (SNOMED CT-2)
Item Group
Tumorhistologie
Pathologisches Institut
Item
General pathology department
string
C0587490 (UMLS CUI-1)
309953001 (SNOMED CT-1)
Histologie-Einsendenummer
Item
Histopathology-number
string
must_have (Item-Info)
Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Nummer/Identifier (Code-2)
C0600091 (UMLS CUI-2)
118522005 (SNOMED CT-2)
MTHU003116 (LOINC-2)
Aufnahme-Nr. WHK
Item
Admission Information
string
Admission Information (Code-1)
C2599639 (UMLS CUI-1)
Item Group
Histopathology
Histologie-Datum
Item
Date of Histology
date
must_have (Item-Info)
Date of pathology report (observable entity) (Code-1)
C1302659 (UMLS CUI-1)
399737008 (SNOMED CT-1)
Eingangszeit
Item
Time of entry
string
Date of entry (Code-1)
C1978797 (UMLS CUI-1)
MTHU026971 (LOINC-1)
Histologie ICD-0-3
Item
Histology ICD-O-3
string
must_have (Item-Info)
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
sonstige Histologie
Item
Histopathology
string
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
Biopsy (Code-3)
C0005558 (UMLS CUI-3)
86273004 (SNOMED CT-3)
10004720 (MedDRA-3)
MTHU028106 (LOINC-3)
mit ICD-0-3
Item
Histology ICD-O-3
string
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
Biopsy (Code-3)
C0005558 (UMLS CUI-3)
86273004 (SNOMED CT-3)
10004720 (MedDRA-3)
MTHU028106 (LOINC-3)
Item Group
Stanzen
Item
Biopsy Site
integer
C1301128 (UMLS CUI-1)
396991001 (SNOMED CT-1)
Ort der Stanze
Code List
Biopsy Site
CL Item
right apical medial (RAM)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Apical (Code-2)
C0205111 (UMLS CUI-2)
43674008 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
right apical lateral (RAL)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Apical (Code-2)
C0205112 (UMLS CUI-2)
43674009 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
right concentric medial (RMM)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Concentric (Code-2)
C0439744 (UMLS CUI-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
right concentric lateral (RML)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Concentric (Code-2)
C0439745 (UMLS CUI-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
right basal medial (RBM)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Basal (Code-2)
C0205112 (UMLS CUI-2)
57195005 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
right basal lateral (RBL)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Basal (Code-2)
C0205113 (UMLS CUI-2)
57195006 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
left apical medial (LAM)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Apical (Code-2)
C0205111 (UMLS CUI-2)
43674008 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
left apical lateral (LAL)
Left (Code-1)
C0205092 (UMLS CUI-1)
7771001 (SNOMED CT-1)
Apical (Code-2)
C0205112 (UMLS CUI-2)
43674009 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
left concentric medial (LMM)
Left (Code-1)
C0205093 (UMLS CUI-1)
7771002 (SNOMED CT-1)
Concentric (Code-2)
C0439744 (UMLS CUI-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
left concentric lateral (LML)
Left (Code-1)
C0205094 (UMLS CUI-1)
7771003 (SNOMED CT-1)
Concentric (Code-2)
C0439745 (UMLS CUI-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
left basal medial (LBM)
Left (Code-1)
C0205095 (UMLS CUI-1)
7771004 (SNOMED CT-1)
Basal (Code-2)
C0205112 (UMLS CUI-2)
57195005 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
left basal lateral (LBL)
Left (Code-1)
C0205096 (UMLS CUI-1)
7771005 (SNOMED CT-1)
Basal (Code-2)
C0205113 (UMLS CUI-2)
57195006 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
Add (Zusatz)
Additional (Code-1)
C1524062 (UMLS CUI-1)
MTHU013802 (LOINC-1)
Item Group
Stanze
Stanze
Item
Biopsy
integer
for_compare (Code-Info)
Biopsy (Code-1)
C0005558 (UMLS CUI-1)
86273004 (SNOMED CT-1)
10004720 (MedDRA-1)
MTHU028106 (LOINC-1)
durchgeführt
Item
executed
integer
changed_datatype (Code-Info)
Execution (Code-1)
C1705848 (UMLS CUI-1)
kein Tumornachweis
Item
No tumor present in specimen
boolean
No tumor present in specimen (finding) (Code-1)
C1300994 (UMLS CUI-1)
396796000 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-Summe
Item
Total Gleason Score for Prostate Cancer
integer
C1273607 (UMLS CUI-1)
384997002 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-1
Item
Primary Gleason Pattern
integer
C1273604 (UMLS CUI-1)
384994009 (SNOMED CT-1)
MTHU020049 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-2
Item
Secondary Gleason Pattern
integer
C1273605 (UMLS CUI-1)
384995005 (SNOMED CT-1)
MTHU020050 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Tumor in % der Stanze
Item
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma
string
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma (observable entity) (Code-1)
C1272841 (UMLS CUI-1)
385396009 (SNOMED CT-1)
Länge (in mm)
Item
Length of specimen
string
Length of core in specimen obtained by needle biopsy (observable entity) (Code-1)
C1302538 (UMLS CUI-1)
99598003 (SNOMED CT-1)
sonstige Information
Item
Other useful information
string
C2598196 (UMLS CUI-1)
MTHU029932 (LOINC-1)
ASAP
Item
Atypical Small Acinar Proliferation of the Prostate Gland
boolean
C1332353 (UMLS CUI-1)
PIN-HG
Item
High Grade Prostatic Intraepithelial Neoplasia
boolean
C1168327 (UMLS CUI-1)
446711009 (SNOMED CT-1)
Prostatis
Item
prostatitis
boolean
C0033581 (UMLS CUI-1)
9713002 (SNOMED CT-1)
10036978 (MedDRA-1)
N41.9 (ICD-10-CM-1)
601.9 (ICD-9-CM-1)
Nekrosen
Item
Necrosis
boolean
C0027540 (UMLS CUI-1)
6574001 (SNOMED CT-1)
10028851 (MedDRA-1)
Samenblaseninfiltration
Item
Seminal vesicle invasion
boolean
Seminal vesicle invasion by tumor present (finding) (Code-1)
C1268952 (UMLS CUI-1)
372294007 (SNOMED CT-1)
extraprostat. Ausbreitung
Item
extraprostatic extension
boolean
Extraprostatic extension of tumor present (finding) (Code-1)
C1276734 (UMLS CUI-1)
372306004 (SNOMED CT-1)
Perineuralscheideninvasion
Item
Perineural invasion
boolean
Perineural invasion finding (Code-1)
C1300724 (UMLS CUI-1)
396394004 (SNOMED CT-1)
p63 (negativ)
Item
TP63 protein
boolean
TP63 protein, human (Code-1)
C1431519 (UMLS CUI-1)
Negative Finding (Code-2)
C0205160 (UMLS CUI-2)
260385009 (SNOMED CT-2)
AMACR (positiv)
Item
Alpha-Methylacyl-CoA Racemase
boolean
C0666209 (UMLS CUI-1)
130879000 (SNOMED CT-1)
Positive Finding (Code-2)
C1446409 (UMLS CUI-2)
10828004 (SNOMED CT-2)
Item Group
Site of distant metastasis
Lokalisation 1
Item
Site of distant metastasis
string
Site of distant metastasis (observable entity) (Code-1)
C0807944 (UMLS CUI-1)
385421009 (SNOMED CT-1)
MTHU010380 (LOINC-1)
Datum
Item
Date in time
date
Date of diagnosis (observable entity) (Code-1)
C2316983 (UMLS CUI-1)
432213005 (SNOMED CT-1)
MTHU038128 (LOINC-1)
Distant Metastasis (Code-2)
CL278860 (UMLS CUI-2)
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