ID

4106

Beskrivning

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

Nyckelord

Versioner (1)
  1. 2013-08-07 2013-08-07 -
Uppladdad den

7 augusti 2013

DOI

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HIS pathology report - biopsy prostate cancer

Tysk Engelsk

HIS

1 Formulär  
  1. StudyEvent: HIS
    1. HIS
Admininstrative Daten
Beskrivning

Admininstrative Daten

Patienten-Nachname
Beskrivning

Name

Datatyp

string

Alias
UMLS CUI-1
C0421448
SNOMED CT-1
184096005
Patienten-Vorname
Beskrivning

Vorname

Datatyp

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patienten-Titel
Beskrivning

Titel

Datatyp

string

Alias
Code-1
Patient title (observable entity)
UMLS CUI-1
C0421450
SNOMED CT-1
184098006
früherer Name
Beskrivning

früherer Name

Datatyp

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
Patienten-Geburtsdatum
Beskrivning

Geburtsdatum

Datatyp

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Alter des Patienten
Beskrivning

Alter

Datatyp

integer

Alias
Code-1
patient age
UMLS CUI-1
CL386174
Nationalität/Staatsangehörigkeit
Beskrivning

Nationalität

Datatyp

string

Alias
UMLS CUI-1
C0438960
SNOMED CT-1
186034007
Code-2
Patients
UMLS CUI-2
C0030705
SNOMED CT-2
116154003
Straße
Beskrivning

Adresse

Datatyp

string

Alias
UMLS CUI-1
C1301826
SNOMED CT-1
398099009
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
Postleitzahl Patient
Beskrivning

PLZ

Datatyp

integer

Alias
UMLS CUI-1
C0421454
SNOMED CT-1
184102003
Wohnort
Beskrivning

Stadt

Datatyp

string

Alias
UMLS CUI-1
C2316883
SNOMED CT-1
433178008
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
Fallnummer
Beskrivning

Fallnummer

Datatyp

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
Beskrivning

Tumorhistologie

Pathologisches Institut
Beskrivning

Pathologisches Institut

Datatyp

string

Alias
UMLS CUI-1
C0587490
SNOMED CT-1
309953001
Histologie-Identifikationsnummer
Beskrivning

Histologie-Einsendenummer

Datatyp

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
Aufnahme-Information
Beskrivning

Aufnahme-Nr. WHK

Datatyp

string

Alias
Code-1
Admission Information
UMLS CUI-1
C2599639
Histopathologie
Beskrivning

Histopathologie

Datum der Histologie
Beskrivning

Histologie-Datum

Datatyp

date

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

Eingangszeit

Datatyp

string

Alias
Code-1
Date of entry
UMLS CUI-1
C1978797
LOINC-1
MTHU026971
Histologie-Code ICD-0-3
Beskrivning

Histologie ICD-0-3

Datatyp

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
Histopathologie
Beskrivning

sonstige Histologie

Datatyp

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
Histologie-Code ICD-0-3
Beskrivning

mit ICD-0-3

Datatyp

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
Beskrivning

Stanzen

Ort der Biopsie
Beskrivning

Ort der Stanze

Datatyp

integer

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

Stanze

Biopsie
Beskrivning

Stanze

Datatyp

integer

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

durchgeführt

Datatyp

integer

Alias
Code-Info
changed_datatype
Code-1
Execution
UMLS CUI-1
C1705848
kein Tumornachweis
Beskrivning

kein Tumornachweis

Datatyp

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
Gesamt-Gleason-Score
Beskrivning

Gleason-Summe

Datatyp

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
vorangiges Gleason-Muster
Beskrivning

Gleason-1

Datatyp

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
zweithäufigstes Gleason-Muster
Beskrivning

Gleason-2

Datatyp

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
Tumor in % der Stanze
Beskrivning

Tumor in % der Stanze

Datatyp

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
Länge (in mm)
Beskrivning

Länge (in mm)

Datatyp

string

Alias
Code-1
Length of core in specimen obtained by needle biopsy (observable entity)
UMLS CUI-1
C1302538
SNOMED CT-1
99598003
sonstige nützliche Informationen
Beskrivning

sonstige Information

Datatyp

string

Alias
UMLS CUI-1
C2598196
LOINC-1
MTHU029932
atypische klein-azinäre Proliferation der Prostata
Beskrivning

ASAP

Datatyp

boolean

Alias
UMLS CUI-1
C1332353
PIN-High Grade
Beskrivning

PIN-HG

Datatyp

boolean

Alias
UMLS CUI-1
C1168327
SNOMED CT-1
446711009
Prostatitis
Beskrivning

Prostatis

Datatyp

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
Nekrosen
Beskrivning

Nekrosen

Datatyp

boolean

Alias
UMLS CUI-1
C0027540
SNOMED CT-1
6574001
MedDRA-1
10028851
Samenblaseninfiltration
Beskrivning

Samenblaseninfiltration

Datatyp

boolean

Alias
Code-1
Seminal vesicle invasion by tumor present (finding)
UMLS CUI-1
C1268952
SNOMED CT-1
372294007
extraprostatische Tumorausbreitung
Beskrivning

extraprostat. Ausbreitung

Datatyp

boolean

Alias
Code-1
Extraprostatic extension of tumor present (finding)
UMLS CUI-1
C1276734
SNOMED CT-1
372306004
Perineurale Invasion
Beskrivning

Perineuralscheideninvasion

Datatyp

boolean

Alias
Code-1
Perineural invasion finding
UMLS CUI-1
C1300724
SNOMED CT-1
396394004
p63 (negativ)
Beskrivning

p63 (negativ)

Datatyp

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
Beskrivning

AMACR (positiv)

Datatyp

boolean

Alias
UMLS CUI-1
C0666209
SNOMED CT-1
130879000
Code-2
Positive Finding
UMLS CUI-2
C1446409
SNOMED CT-2
10828004
Lokalisation Fernmetastase
Beskrivning

Lokalisation Fernmetastase

Lokalisation Fernmetastase
Beskrivning

Lokalisation 1

Datatyp

string

Alias
Code-1
Site of distant metastasis (observable entity)
UMLS CUI-1
C0807944
SNOMED CT-1
385421009
LOINC-1
MTHU010380
Datum
Beskrivning

Datum

Datatyp

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
Tillbaka till toppen

Similar models

HIS

1 Formulär
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Admininstrative Daten
Name
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)
Titel
Item
Patienten-Titel
string
Patient title (observable entity) (Code-1)
C0421450 (UMLS CUI-1)
184098006 (SNOMED CT-1)
früherer Name
Item
früherer 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
Patienten-Geburtsdatum
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Alter
Item
Alter des Patienten
integer
patient age (Code-1)
CL386174 (UMLS CUI-1)
Nationalität
Item
Nationalität/Staatsangehörigkeit
string
C0438960 (UMLS CUI-1)
186034007 (SNOMED CT-1)
Patients (Code-2)
C0030705 (UMLS CUI-2)
116154003 (SNOMED CT-2)
Adresse
Item
Straße
string
C1301826 (UMLS CUI-1)
398099009 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
PLZ
Item
Postleitzahl Patient
integer
C0421454 (UMLS CUI-1)
184102003 (SNOMED CT-1)
Stadt
Item
Wohnort
string
C2316883 (UMLS CUI-1)
433178008 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
Fallnummer
Item
Fallnummer
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
Pathologisches Institut
string
C0587490 (UMLS CUI-1)
309953001 (SNOMED CT-1)
Histologie-Einsendenummer
Item
Histologie-Identifikationsnummer
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
Aufnahme-Information
string
Admission Information (Code-1)
C2599639 (UMLS CUI-1)
Item Group
Histopathologie
Histologie-Datum
Item
Datum der Histologie
date
must_have (Item-Info)
Date of pathology report (observable entity) (Code-1)
C1302659 (UMLS CUI-1)
399737008 (SNOMED CT-1)
Eingangszeit
Item
Eingangszeit
string
Date of entry (Code-1)
C1978797 (UMLS CUI-1)
MTHU026971 (LOINC-1)
Histologie ICD-0-3
Item
Histologie-Code ICD-0-3
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
Histopathologie
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
Histologie-Code ICD-0-3
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
Ort der Biopsie
integer
C1301128 (UMLS CUI-1)
396991001 (SNOMED CT-1)
Ort der Stanze
Code List
Ort der Biopsie
CL Item
rechts apikal 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
rechts apikal 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
rechts mittig 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
rechts mittig 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
rechts 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
rechts 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
links apikal 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
links apikal 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
links mittig 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
links mittig 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
links 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
links 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
Zusatz (Zusatz)
Additional (Code-1)
C1524062 (UMLS CUI-1)
MTHU013802 (LOINC-1)
Item Group
Stanze
Stanze
Item
Biopsie
integer
for_compare (Code-Info)
Biopsy (Code-1)
C0005558 (UMLS CUI-1)
86273004 (SNOMED CT-1)
10004720 (MedDRA-1)
MTHU028106 (LOINC-1)
durchgeführt
Item
durchgeführt
integer
changed_datatype (Code-Info)
Execution (Code-1)
C1705848 (UMLS CUI-1)
kein Tumornachweis
Item
kein Tumornachweis
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
Gesamt-Gleason-Score
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
vorangiges Gleason-Muster
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
zweithäufigstes Gleason-Muster
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
Tumor in % der Stanze
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
Länge (in mm)
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
sonstige nützliche Informationen
string
C2598196 (UMLS CUI-1)
MTHU029932 (LOINC-1)
ASAP
Item
atypische klein-azinäre Proliferation der Prostata
boolean
C1332353 (UMLS CUI-1)
PIN-HG
Item
PIN-High Grade
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
Nekrosen
boolean
C0027540 (UMLS CUI-1)
6574001 (SNOMED CT-1)
10028851 (MedDRA-1)
Samenblaseninfiltration
Item
Samenblaseninfiltration
boolean
Seminal vesicle invasion by tumor present (finding) (Code-1)
C1268952 (UMLS CUI-1)
372294007 (SNOMED CT-1)
extraprostat. Ausbreitung
Item
extraprostatische Tumorausbreitung
boolean
Extraprostatic extension of tumor present (finding) (Code-1)
C1276734 (UMLS CUI-1)
372306004 (SNOMED CT-1)
Perineuralscheideninvasion
Item
Perineurale Invasion
boolean
Perineural invasion finding (Code-1)
C1300724 (UMLS CUI-1)
396394004 (SNOMED CT-1)
p63 (negativ)
Item
p63 (negativ)
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
Lokalisation Fernmetastase
Lokalisation 1
Item
Lokalisation Fernmetastase
string
Site of distant metastasis (observable entity) (Code-1)
C0807944 (UMLS CUI-1)
385421009 (SNOMED CT-1)
MTHU010380 (LOINC-1)
Datum
Item
Datum
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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