ID

10222

Description

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

Keywords

  1. 8/7/13 8/7/13 -
  2. 5/17/15 5/17/15 - Martin Dugas
  3. 9/27/21 9/27/21 -
Uploaded on

May 17, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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documentation standard - breast cancer - talk after biopsy

  1. StudyEvent: HIS
    1. HIS
Administrative information
Description

Administrative information

Alias
UMLS CUI-1
C3845829
Admission date
Description

Aufnahmedatum

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Patient Identification Number
Description

PatientenID

Data type

integer

Alias
Code-1
Patients
UMLS CUI-1
C0030705
SNOMED CT-1
116154003
Code-2
Identification number
UMLS CUI-2
C1300638
SNOMED CT-2
396278008
Patient sex
Description

Geschlecht

Data type

string

Alias
UMLS CUI-1
C0150831
SNOMED CT-1
184100006
Patient surname
Description

Nachname

Data type

string

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

Vorname

Data type

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patient date of birth
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Admission hour
Description

Aufnahmezeit

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Code-2
Hour
UMLS CUI-2
C0439227
SNOMED CT-2
258702006
HL7 V3-2
HR
Physician admission
Description

E-Arzt

Data type

string

Alias
Code-1
Admission
UMLS CUI-1
C0809949
Code-2
Physicians
UMLS CUI-2
C0031831
SNOMED CT-2
112247003
LOINC-2
MTHU010489
HL7 V3-2
PHYS
Patient information
Description

Patient information

Alias
UMLS CUI-1
C1955348
date
Description

am

Data type

date

Alias
Code-1
Visit Date
UMLS CUI-1
C1320303
SNOMED CT-1
406543005
responsible person
Description

durch Dr.

Data type

string

Alias
Code-1
Responsible Person
UMLS CUI-1
C1273518
SNOMED CT-1
394851003
Histopathology
Description

Histologie

Data type

string

Alias
Code-1
Histopathology
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Operative Surgical Procedures
Description

Operative Surgical Procedures

Excisional Biopsy
Description

DE

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Excisional Biopsy
UMLS CUI-1
C0184921
SNOMED CT-1
8889005
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Breast Conservation Treatment
Description

BET

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Breast Conservation Treatment
UMLS CUI-1
C0917927
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
reconstructive breast conservation treatment
Description

onkopl. BET

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Plastic Surgical Procedures
UMLS CUI-1
C0677616
SNOMED CT-1
286553006
MedDRA-1
10062082
Code-2
Breast Conservation Treatment
UMLS CUI-2
C0917927
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
mastectomy
Description

ME

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Mastectomy
UMLS CUI-1
C0024881
MedDRA-1
10026878
ICD-9-CM-1
85.4
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Operative Surgical Procedures
Description

geplante Operation II

Data type

integer

Alias
UMLS CUI-1
C0543467
SNOMED CT-1
387713003
MedDRA-1
10042609
LOINC-1
MTHU007597
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Sentinel Lymph Node Biopsy
Description

SLN

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Sentinel Lymph Node Biopsy
UMLS CUI-1
C0796693
SNOMED CT-1
396487001
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Axillary Lymph Node Dissection
Description

aLNE

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Axillary Lymph Node Dissection
UMLS CUI-1
C0193867
SNOMED CT-1
234254000
MedDRA-1
10068477
ICD-9-CM-1
40.23
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Reconstructive Surgical Procedure
Description

Rekonstruktion gewünscht

Data type

integer

Alias
Code-1
Reconstructive Surgical Procedures
UMLS CUI-1
C0524865
SNOMED CT-1
122465003
LOINC-1
MTHU010401
Date of admission
Description

stationäre Aufnahme am

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
primary surgeon
Description

verantwortlicher Operateur

Data type

string

Alias
Code-1
primary surgeon
UMLS CUI-1
C0808118
LOINC-1
MTHU010488
HL7 V3-1
PRISURG
Patient information II
Description

Patient information II

Alias
UMLS CUI-1
C1955348
Intention Chemotherpy
Description

Intention Chemotherpy

Data type

text

Alias
Code-Info
normalized_coding
Code-1
Intention
SNOMED CT-1
367565008
Code-2
Chemotherapy Regimen
SNOMED CT-2
69960004
MedDRA-2
10061758
Code-3
Plan
SNOMED CT-3
397943006
UMLS CUI-1
C1283828
UMLS CUI-2
C0392920
UMLS CUI-3
C1301732
Clinical Trials
Description

Studie

Data type

string

Alias
UMLS CUI-1
C0008976
SNOMED CT-1
110465008
disease stage
Description

Staging

Data type

integer

Alias
Code-1
disease stage
UMLS CUI-1
C0699749
X-Ray of Thorax
Description

Rö-Thorax

Data type

boolean

Alias
Code-1
Radiographic imaging procedure
UMLS CUI-1
C1962945
SNOMED CT-1
363680008
MedDRA-1
10048064
Code-2
Thorax
UMLS CUI-2
C0817096
SNOMED CT-2
51185008
date X-Ray of Thorax
Description

Rö-Thorax

Data type

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Radiographic imaging procedure
UMLS CUI-2
C1962945
SNOMED CT-2
363680008
MedDRA-2
10048064
finding X-Ray of Thorax - free text
Description

Befund Rö-Thorax

Data type

string

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
Radiographic imaging procedure
UMLS CUI-2
C1962945
SNOMED CT-2
363680008
MedDRA-2
10048064
Code-3
Free Text Format
UMLS CUI-3
C2348713
finding X-Ray of Thorax
Description

Befund II Rö-Thorax

Data type

integer

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
Radiographic imaging procedure
UMLS CUI-2
C1962945
SNOMED CT-2
363680008
MedDRA-2
10048064
Ultrasonography of Abdomen
Description

OB-Sono

Data type

boolean

Alias
Code-1
Ultrasonography
UMLS CUI-1
C0041618
SNOMED CT-1
16310003
MedDRA-1
10045434
LOINC-1
MTHU000076
CTCAE-1
12
Code-2
Abdomen
UMLS CUI-2
C0000726
SNOMED CT-2
113345001
LOINC-2
MTHU001425
date Ultrasonography of Abdomen
Description

OB-Sono

Data type

date

Alias
Code-1
Ultrasonography
UMLS CUI-1
C0041618
SNOMED CT-1
16310003
MedDRA-1
10045434
LOINC-1
MTHU000076
finding Ultrasonography of Abdomen - free text
Description

Befund OB-Sono

Data type

string

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
Ultrasonography
UMLS CUI-2
C0041618
SNOMED CT-2
16310003
MedDRA-2
10045434
LOINC-2
MTHU000076
Code-3
Free Text Format
UMLS CUI-3
C2348713
finding Ultrasonography of Abdomen
Description

Befund II OB-Sono

Data type

integer

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
Ultrasonography
UMLS CUI-2
C0041618
SNOMED CT-2
16310003
MedDRA-2
10045434
LOINC-2
MTHU000076
Scintigraphy
Description

Skelett-Szinitigr.

Data type

boolean

Alias
Code-1
Radionuclide Imaging
UMLS CUI-1
C0034606
SNOMED CT-1
399019003
MedDRA-1
10061478
ICD-9-CM-1
92
date scintigraphy
Description

Skelett-Szinitigr.

Data type

date

Alias
Code-1
Radionuclide Imaging
UMLS CUI-1
C0034606
SNOMED CT-1
399019003
MedDRA-1
10061478
ICD-9-CM-1
92
finding scintigraphy - free text
Description

Befund Skelett-Szinitigr.

Data type

string

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
Radionuclide Imaging
UMLS CUI-2
C0034606
SNOMED CT-2
399019003
MedDRA-2
10061478
ICD-9-CM-2
92
Code-3
Free Text Format
UMLS CUI-3
C2348713
finding scintigraphy
Description

Befund II Skelett-Szinitigr.

Data type

integer

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
Radionuclide Imaging
UMLS CUI-2
C0034606
SNOMED CT-2
399019003
MedDRA-2
10061478
ICD-9-CM-2
92
X-Ray Computed Tomography
Description

Computertomogr.

Data type

boolean

Alias
Code-1
X-Ray Computed Tomography
UMLS CUI-1
C0040405
SNOMED CT-1
77477000
MedDRA-1
10010234
date X-Ray Computed Tomography
Description

Computertomogr.

Data type

date

Alias
Code-1
X-Ray Computed Tomography
UMLS CUI-1
C0040405
SNOMED CT-1
77477000
MedDRA-1
10010234
finding X-Ray Computed Tomography - free text
Description

Befund Computertomogr.

Data type

string

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
X-Ray Computed Tomography
UMLS CUI-2
C0040405
SNOMED CT-2
77477000
MedDRA-2
10010234
Code-3
Free Text Format
UMLS CUI-3
C2348713
finding X-Ray Computed Tomography
Description

Befund II Computertomogr.

Data type

integer

Alias
Code-1
Finding
UMLS CUI-1
C1285578
SNOMED CT-1
363787002
Code-2
X-Ray Computed Tomography
UMLS CUI-2
C0040405
SNOMED CT-2
77477000
MedDRA-2
10010234
distant metastasis
Description

Metastasen (M1)

Data type

string

Alias
Code-1
Distant Metastasis
UMLS CUI-1
CL278860
second opinion desired
Description

Patientin wünscht Zweitmeinung

Data type

boolean

Alias
Code-1
Second Opinion
UMLS CUI-1
C0036524
Code-2
desire
UMLS CUI-2
C0871633
place second opinion
Description

Ort Zweitmeinung

Data type

string

Alias
Code-1
Second Opinion
UMLS CUI-1
C0036524
Code-2
Place
UMLS CUI-2
C0442504
SNOMED CT-2
257557008
Signature
Description

Unterschrift

Data type

string

Alias
Code-1
Signature of responsible attending physician on file
UMLS CUI-1
C0807938

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative information
C3845829 (UMLS CUI-1)
Aufnahmedatum
Item
Admission date
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
PatientenID
Item
Patient Identification Number
integer
Patients (Code-1)
C0030705 (UMLS CUI-1)
116154003 (SNOMED CT-1)
Identification number (Code-2)
C1300638 (UMLS CUI-2)
396278008 (SNOMED CT-2)
Geschlecht
Item
Patient sex
string
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
Nachname
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)
Geburtsdatum
Item
Patient date of birth
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Aufnahmezeit
Item
Admission hour
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)
E-Arzt
Item
Physician admission
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)
Item Group
Patient information
C1955348 (UMLS CUI-1)
am
Item
date
date
Visit Date (Code-1)
C1320303 (UMLS CUI-1)
406543005 (SNOMED CT-1)
durch Dr.
Item
responsible person
string
Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
Histologie
Item
Histopathology
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)
Item Group
Operative Surgical Procedures
DE
Item
Excisional Biopsy
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)
BET
Item
Breast Conservation Treatment
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)
onkopl. BET
Item
reconstructive breast conservation treatment
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)
ME
Item
mastectomy
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)
geplante Operation II
Item
Operative Surgical Procedures
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)
SLN
Item
Sentinel Lymph Node Biopsy
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)
aLNE
Item
Axillary Lymph Node Dissection
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)
Item
Reconstructive Surgical Procedure
integer
Reconstructive Surgical Procedures (Code-1)
C0524865 (UMLS CUI-1)
122465003 (SNOMED CT-1)
MTHU010401 (LOINC-1)
Code List
Reconstructive Surgical Procedure
CL Item
not required (nicht notwendig)
Requirement (Code-1)
C1514873 (UMLS CUI-1)
Negation (Code-2)
C1518422 (UMLS CUI-2)
CL Item
No (nein, aber Aufklärung erfolgt)
No (Code-1)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Yes (ja)
Yes (Code-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)
CL Item
latissimus dorsi muscle flap (Lat. Dorsi)
Reconstruction of breast using myocutaneous flap of latissimus dorsi muscle (procedure) (Code-1)
C0405407 (UMLS CUI-1)
172057008 (SNOMED CT-1)
CL Item
Transverse Rectus Abdominis Myocutaneous flap (TRAM)
extended_coding (Code-Info)
Breast reconstruction with TRAM flap (procedure) (Code-1)
C0521240 (UMLS CUI-1)
70966003 (SNOMED CT-1)
10044333 (MedDRA-1)
CL Item
deep inferior epigastric perforators (DIEP)
extended_coding (Code-Info)
DIEP Flap (Code-1)
C2985549 (UMLS CUI-1)
stationäre Aufnahme am
Item
Date of admission
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
verantwortlicher Operateur
Item
primary surgeon
string
primary surgeon (Code-1)
C0808118 (UMLS CUI-1)
MTHU010488 (LOINC-1)
PRISURG (HL7 V3-1)
Item Group
Patient information II
C1955348 (UMLS CUI-1)
Item
Intention Chemotherpy
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)
Code List
Intention Chemotherpy
CL Item
Neo-adjuvant - intent (N)
C1298676 (UMLS CUI-1)
Studie
Item
Clinical Trials
string
C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)
Item
disease stage
integer
disease stage (Code-1)
C0699749 (UMLS CUI-1)
Code List
disease stage
CL Item
Preoperative (präoperativ)
Preoperative (Code-1)
C0445204 (UMLS CUI-1)
262068006 (SNOMED CT-1)
CL Item
Postoperative (postoperativ)
Postoperative (Code-1)
C0032790 (UMLS CUI-1)
262061000 (SNOMED CT-1)
Rö-Thorax
Item
X-Ray of 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)
Rö-Thorax
Item
date X-Ray of 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)
Befund Rö-Thorax
Item
finding X-Ray of Thorax - free text
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)
Item
finding X-Ray of 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)
Code List
finding X-Ray of Thorax
CL Item
Normal (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
Abnormal  (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
OB-Sono
Item
Ultrasonography of 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)
OB-Sono
Item
date Ultrasonography of Abdomen
date
Ultrasonography (Code-1)
C0041618 (UMLS CUI-1)
16310003 (SNOMED CT-1)
10045434 (MedDRA-1)
MTHU000076 (LOINC-1)
Befund OB-Sono
Item
finding Ultrasonography of Abdomen - free text
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)
Item
finding Ultrasonography of 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)
Code List
finding Ultrasonography of Abdomen
CL Item
Normal (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
Abnormal  (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Skelett-Szinitigr.
Item
Scintigraphy
boolean
Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)
Skelett-Szinitigr.
Item
date scintigraphy
date
Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)
Befund Skelett-Szinitigr.
Item
finding scintigraphy - free text
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)
Item
finding scintigraphy
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)
Code List
finding scintigraphy
CL Item
Normal (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
Abnormal  (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Computertomogr.
Item
X-Ray Computed Tomography
boolean
X-Ray Computed Tomography (Code-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)
Computertomogr.
Item
date X-Ray Computed Tomography
date
X-Ray Computed Tomography (Code-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)
Befund Computertomogr.
Item
finding X-Ray Computed Tomography - free text
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)
Item
finding X-Ray Computed Tomography
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)
Code List
finding X-Ray Computed Tomography
CL Item
Normal (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
Abnormal  (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Metastasen (M1)
Item
distant metastasis
string
Distant Metastasis (Code-1)
CL278860 (UMLS CUI-1)
Patientin wünscht Zweitmeinung
Item
second opinion desired
boolean
Second Opinion (Code-1)
C0036524 (UMLS CUI-1)
desire (Code-2)
C0871633 (UMLS CUI-2)
Ort Zweitmeinung
Item
place second opinion
string
Second Opinion (Code-1)
C0036524 (UMLS CUI-1)
Place (Code-2)
C0442504 (UMLS CUI-2)
257557008 (SNOMED CT-2)
Unterschrift
Item
Signature
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)

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