ID

4110

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 -
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7 augusti 2013

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HIS surgery form prostate cancer

Tysk Engelsk

HIS

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

Admininstrative Daten

Patient surname
Beskrivning

Name

Datatyp

string

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

Vorname

Datatyp

string

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

Titel

Datatyp

string

Alias
Code-1
Patient title (observable entity)
UMLS CUI-1
C0421450
SNOMED CT-1
184098006
former Patient 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
Patient date of birth
Beskrivning

Geburtsdatum

Datatyp

date

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

Alter

Datatyp

integer

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

Nationalität

Datatyp

string

Alias
UMLS CUI-1
C0438960
SNOMED CT-1
186034007
Code-2
Patients
UMLS CUI-2
C0030705
SNOMED CT-2
116154003
Street Address
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
Patient postal code
Beskrivning

PLZ

Datatyp

integer

Alias
UMLS CUI-1
C0421454
SNOMED CT-1
184102003
City of residence
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
Case Identifier
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
OP-Bogen
Beskrivning

OP-Bogen

Cancer Diagnosis
Beskrivning

Tumordiagnose (ICD-10)

Datatyp

string

Alias
Code-1
Tumor finding (finding)
UMLS CUI-1
C1274082
SNOMED CT-1
395557000
Code-2
Diagnosis ICD code
UMLS CUI-2
C2598420
Date of diagnosis
Beskrivning

Diagnose-Datum

Datatyp

date

Alias
UMLS CUI-1
C2316983
SNOMED CT-1
432213005
Code-2
Tumor finding (finding)
UMLS CUI-2
C1274082
SNOMED CT-2
395557000
Date of surgery
Beskrivning

Datum

Datatyp

date

Alias
Code-1
Date surgery
UMLS CUI-1
C1628561
LOINC-1
MTHU019327
Guideline Adherence
Beskrivning

Wird die Therapie nach Leitlinien durchgeführt

Datatyp

boolean

Alias
Item-Info
must_have
UMLS CUI-1
C0525059
Reason for Guidelines Adherence
Beskrivning

Grund

Datatyp

string

Alias
Code-1
Indication of (contextual qualifier)
UMLS CUI-1
C0392360
SNOMED CT-1
410666004
LOINC-1
MTHU008862
Code-2
Guideline Adherence
UMLS CUI-2
C0525059
ASA physical status
Beskrivning

ASA

Datatyp

integer

Alias
Code-1
Finding of American Society of Anesthesiologists physical status classification (finding)
UMLS CUI-1
C1531480
SNOMED CT-1
413347006
Operative Surgical Procedure
Beskrivning

Operative Surgical Procedure

Surgical and medical procedures
Beskrivning

OPS-2010

Datatyp

string

Alias
Item-Info
must_have
Code-1
Surgical and medical procedures
UMLS CUI-1
C1948041
SNOMED CT-1
71388002
LOINC-1
MTHU006237
Side
Beskrivning

Seite

Datatyp

integer

Alias
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Tumor site
UMLS CUI-2
C0475445
SNOMED CT-2
263591006
LOINC-2
MTHU015562
Intent
Beskrivning

Ziel

Datatyp

integer

Alias
UMLS CUI-1
C1283828
SNOMED CT-1
367565008
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Which Operative Surgical Procedures
Beskrivning

welche

Datatyp

string

Alias
Code-1
Operative Surgical Procedures
UMLS CUI-1
C0543467
SNOMED CT-1
387713003
MedDRA-1
10042609
LOINC-1
MTHU007597
Code-2
Free Text Format
UMLS CUI-2
C2348713
Nerve-Sparing
Beskrivning

Nerverhalt

Datatyp

boolean

Alias
Code-1
Nerve-Sparing Prostatectomy
UMLS CUI-1
C1514120
Side
Beskrivning

falls ja, wo?

Datatyp

integer

Alias
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Nerve-Sparing Prostatectomy
UMLS CUI-2
C1514120
primary surgeon
Beskrivning

Name des Operateurs

Datatyp

string

Alias
Item-Info
must_have
UMLS CUI-1
C0808118
LOINC-1
MTHU010488
HL7 V3-1
PRISURG
first assistant surgeon
Beskrivning

Lehrassistenz

Datatyp

string

Alias
UMLS CUI-1
C1550491
HL7 V3-1
FASST
additional surgery
Beskrivning

Weitere OP

Datatyp

string

Alias
Code-1
Additional
UMLS CUI-1
C1524062
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Surgical and medical procedures
Beskrivning

OPS-2010 (weitere OP)

Datatyp

string

Alias
Code-1
Surgical and medical procedures
UMLS CUI-1
C1948041
SNOMED CT-1
71388002
LOINC-1
MTHU006237
Side
Beskrivning

Seite

Datatyp

integer

Alias
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Additional
UMLS CUI-2
C1524062
Code-3
Operative Surgical Procedures
UMLS CUI-3
C0543467
SNOMED CT-3
387713003
MedDRA-3
10042609
LOINC-3
MTHU007597
Intent
Beskrivning

Ziel

Datatyp

integer

Alias
UMLS CUI-1
C1283828
SNOMED CT-1
367565008
Code-2
Additional
UMLS CUI-2
C1524062
Code-3
Operative Surgical Procedures
UMLS CUI-3
C0543467
SNOMED CT-3
387713003
MedDRA-3
10042609
LOINC-3
MTHU007597
Intraoperative Complication
Beskrivning

intraoperative Komplikationen

Datatyp

boolean

Alias
Item-Info
must_have
UMLS CUI-1
C0021890
MedDRA-1
10052620
Which Intraoperative Complication
Beskrivning

falls ja, welche

Datatyp

string

Alias
UMLS CUI-1
C0021890
MedDRA-1
10052620
Code-2
Free Text Format
UMLS CUI-2
C2348713
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
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
OP-Bogen
Tumordiagnose (ICD-10)
Item
Cancer Diagnosis
string
Tumor finding (finding) (Code-1)
C1274082 (UMLS CUI-1)
395557000 (SNOMED CT-1)
Diagnosis ICD code (Code-2)
C2598420 (UMLS CUI-2)
Diagnose-Datum
Item
Date of diagnosis
date
C2316983 (UMLS CUI-1)
432213005 (SNOMED CT-1)
Tumor finding (finding) (Code-2)
C1274082 (UMLS CUI-2)
395557000 (SNOMED CT-2)
Datum
Item
Date of surgery
date
Date surgery (Code-1)
C1628561 (UMLS CUI-1)
MTHU019327 (LOINC-1)
Wird die Therapie nach Leitlinien durchgeführt
Item
Guideline Adherence
boolean
must_have (Item-Info)
C0525059 (UMLS CUI-1)
Grund
Item
Reason for Guidelines Adherence
string
Indication of (contextual qualifier) (Code-1)
C0392360 (UMLS CUI-1)
410666004 (SNOMED CT-1)
MTHU008862 (LOINC-1)
Guideline Adherence (Code-2)
C0525059 (UMLS CUI-2)
Item
ASA physical status
integer
Finding of American Society of Anesthesiologists physical status classification (finding) (Code-1)
C1531480 (UMLS CUI-1)
413347006 (SNOMED CT-1)
ASA
Code List
ASA physical status
CL Item
ASA physical status 1 (ASA I: Normaler, gesunder Patient)
American Society of Anesthesiologists physical status class 1 (finding) (Code-1)
C1531504 (UMLS CUI-1)
413495001 (SNOMED CT-1)
CL Item
ASA physical status 2 (ASA II: Patient mit leichter Allgemeinerkrankung)
American Society of Anesthesiologists physical status class 2 (finding) (Code-1)
C1531505 (UMLS CUI-1)
413496000 (SNOMED CT-1)
CL Item
ASA physical status 3 (ASA III: Patient mit schwerer Allgemeinerkrankung)
American Society of Anesthesiologists physical status class 3 (finding) (Code-1)
C1531506 (UMLS CUI-1)
413497009 (SNOMED CT-1)
CL Item
ASA physical status 4 (ASA IV: Patient mit lebensbedrohlicher Allgemeinerkrankung)
American Society of Anesthesiologists physical status class 4 (finding) (Code-1)
C1531507 (UMLS CUI-1)
413498004 (SNOMED CT-1)
Item Group
Operative Surgical Procedure
OPS-2010
Item
Surgical and medical procedures
string
must_have (Item-Info)
Surgical and medical procedures (Code-1)
C1948041 (UMLS CUI-1)
71388002 (SNOMED CT-1)
MTHU006237 (LOINC-1)
Item
Side
integer
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Tumor site (Code-2)
C0475445 (UMLS CUI-2)
263591006 (SNOMED CT-2)
MTHU015562 (LOINC-2)
Seite
Code List
Side
CL Item
Unilateral  (einiseitg)
Unilateral (Code-1)
C0205092 (UMLS CUI-1)
66459002 (SNOMED CT-1)
CL Item
Bilateral (zweiseitig)
Bilateral (Code-1)
C0238767 (UMLS CUI-1)
51440002 (SNOMED CT-1)
Item
Intent
integer
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
Ziel
Code List
Intent
CL Item
Curative - procedure intent  (K = kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Palliative - procedure intent  (P = palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
Diagnostic intent (D = diagnostisch)
Intent For Diagnosis (Code-1)
C0348026 (UMLS CUI-1)
261004008 (SNOMED CT-1)
CL Item
unknown (unbekannt)
Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
welche
Item
Which Operative Surgical Procedures
string
Operative Surgical Procedures (Code-1)
C0543467 (UMLS CUI-1)
387713003 (SNOMED CT-1)
10042609 (MedDRA-1)
MTHU007597 (LOINC-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Nerverhalt
Item
Nerve-Sparing
boolean
Nerve-Sparing Prostatectomy (Code-1)
C1514120 (UMLS CUI-1)
Item
Side
integer
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Nerve-Sparing Prostatectomy (Code-2)
C1514120 (UMLS CUI-2)
falls ja, wo?
Code List
Side
CL Item
Right (rechts)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
Left (links)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
CL Item
Bilateral (beidseits)
C0238767 (UMLS CUI-1)
51440002 (SNOMED CT-1)
Name des Operateurs
Item
primary surgeon
string
must_have (Item-Info)
C0808118 (UMLS CUI-1)
MTHU010488 (LOINC-1)
PRISURG (HL7 V3-1)
Lehrassistenz
Item
first assistant surgeon
string
C1550491 (UMLS CUI-1)
FASST (HL7 V3-1)
Weitere OP
Item
additional surgery
string
Additional (Code-1)
C1524062 (UMLS CUI-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
OPS-2010 (weitere OP)
Item
Surgical and medical procedures
string
Surgical and medical procedures (Code-1)
C1948041 (UMLS CUI-1)
71388002 (SNOMED CT-1)
MTHU006237 (LOINC-1)
Item
Side
integer
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Additional (Code-2)
C1524062 (UMLS CUI-2)
Operative Surgical Procedures (Code-3)
C0543467 (UMLS CUI-3)
387713003 (SNOMED CT-3)
10042609 (MedDRA-3)
MTHU007597 (LOINC-3)
Seite
Code List
Side
CL Item
Unilateral  (einiseitg)
Unilateral (Code-1)
C0205092 (UMLS CUI-1)
66459002 (SNOMED CT-1)
CL Item
Bilateral (zweiseitig)
Bilateral (Code-1)
C0238767 (UMLS CUI-1)
51440002 (SNOMED CT-1)
Item
Intent
integer
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Additional (Code-2)
C1524062 (UMLS CUI-2)
Operative Surgical Procedures (Code-3)
C0543467 (UMLS CUI-3)
387713003 (SNOMED CT-3)
10042609 (MedDRA-3)
MTHU007597 (LOINC-3)
Ziel
Code List
Intent
CL Item
Curative - procedure intent  (K = kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Palliative - procedure intent  (P = palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
Diagnostic intent (D = diagnostisch)
Intent For Diagnosis (Code-1)
C0348026 (UMLS CUI-1)
261004008 (SNOMED CT-1)
CL Item
unknown (unbekannt)
Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
intraoperative Komplikationen
Item
Intraoperative Complication
boolean
must_have (Item-Info)
C0021890 (UMLS CUI-1)
10052620 (MedDRA-1)
falls ja, welche
Item
Which Intraoperative Complication
string
C0021890 (UMLS CUI-1)
10052620 (MedDRA-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Tillbaka till toppen 

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