ID

6459

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

Versions (2)
  1. 5/15/13 5/15/13 -
  2. 12/23/14 12/23/14 - Martin Dugas
Uploaded on

December 23, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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EHR breast cancer

German English

EHR breast cancer

1 forms  
  1. StudyEvent: HIS
    1. EHR breast cancer
Patientenaufkleber groß
Description

Patientenaufkleber groß

Alias
UMLS CUI-1
C1320722
Admission date
Description

Admission date

Data type

date

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

Patient ID

Data type

integer

Alias
Code-1
Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal
LOINC-1
52463-7
UMLS CUI-1
C2706086
Patient sex
Description

Gender

Data type

text

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

Last name

Data type

text

Alias
SNOMED CT-1
184096005
UMLS CUI-1
C1301584
Patient forename
Description

First name

Data type

text

Alias
SNOMED CT-1
184095009
UMLS CUI-1
C1443235
Patient date of birth
Description

Date of Birth

Data type

date

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

Admission time

Data type

time

Alias
Code-1
Date of admission
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Code-2
Hour
SNOMED CT-2
258702006
HL7 V3-2
HR
UMLS CUI-1
C2215405
Physician admission
Description

Referring physician

Data type

text

Alias
Code-1
Admission
Code-2
Physicians
SNOMED CT-2
112247003
LOINC-2
MTHU010489
HL7 V3-2
PHYS
UMLS CUI-1
C1709880
Assessment date
Data type

date

Alias
UMLS CUI-1
C2985720
Anamnesebogen
Description

Anamnesebogen

Alias
UMLS CUI-1
C0262926
Responsible Person for medical case
Description

Anamnese erhoben durch

Data type

string

Alias
Code-1
Responsible Person
UMLS CUI-1
C1273518
SNOMED CT-1
394851003
Code-2
Medical History
UMLS CUI-2
C0262926
SNOMED CT-2
417662000
LOINC-2
MTHU027722
Referring Physician
Description

Zuweisender Arzt

Data type

string

Alias
Code-1
Referring Physician
UMLS CUI-1
C1709880
Gynecologist
Description

FFA

Data type

string

Alias
Code-1
Gynecologist
UMLS CUI-1
C0237419
SNOMED CT-1
83685006
HL7 V3-1
207VG0400X
Reason for Referring
Description

Überweisungsgrund

Data type

string

Alias
Code-1
Referring
UMLS CUI-1
C0205543
Code-2
Indication of (contextual qualifier)
UMLS CUI-2
C0392360
SNOMED CT-2
410666004
LOINC-2
MTHU008862
Reason for patient visit
Description

Grund des Arztbesuches

Data type

integer

Alias
Code-1
Reason for patient visit
UMLS CUI-1
C1704447
SNOMED CT-1
103324002
LOINC-1
MTHU013910
Medical History
Description

Anamnese

Data type

string

Alias
Code-1
Medical History
UMLS CUI-1
C0262926
SNOMED CT-1
417662000
LOINC-1
MTHU027722
Menopause Status
Description

Menopausenstatus

Data type

integer

Alias
Code-1
Menopause finding (finding)
UMLS CUI-1
C0455962
SNOMED CT-1
276477006
quantity of pregnancy
Description

Schwangerschaften

Data type

integer

Alias
Code-1
Finding of quantity of pregnancy (finding)
UMLS CUI-1
C0566634
SNOMED CT-1
289204008
Months of breast feeding
Description

Stillzeit (Monate)

Data type

integer

Alias
Code-1
Months of breast feeding
UMLS CUI-1
C3172259
Drugs
Description

Akuelle Medikamente

Data type

integer

Alias
Code-1
Pharmaceutical Preparations
UMLS CUI-1
C0013227
SNOMED CT-1
410942007
Contraceptives
Description

Pille

Data type

boolean

Alias
Code-1
Contraceptives, Oral
UMLS CUI-1
C0009905
SNOMED CT-1
423938009
Hormone replacement therapy
Description

HRT

Data type

boolean

Alias
Code-1
Hormone replacement therapy
UMLS CUI-1
C0282402
SNOMED CT-1
266717002
MedDRA-1
10020388
Aspirin
Description

ASS

Data type

boolean

Alias
Code-1
Aspirin
UMLS CUI-1
C0004057
SNOMED CT-1
387458008
Phenprocoumon
Description

Marcumar

Data type

boolean

Alias
Code-1
Phenprocoumon
UMLS CUI-1
C0031444
SNOMED CT-1
59488002
LOINC-1
MTHU016364
Allergic Reaction
Description

Allergien

Data type

string

Alias
Code-1
Allergic Reaction
UMLS CUI-1
C1527304
SNOMED CT-1
106190000
MedDRA-1
10020751
ICD-10-CM-1
T78.40
CTCAE-1
E11248
HL7 V3-1
ALG
Tobacco smoking
Description

Nikotin

Data type

boolean

Alias
Code-1
Tobacco smoking behavior
UMLS CUI-1
C0453996
SNOMED CT-1
365981007
How many cigarettes per day do, or did, you smoke
Description

Zig./die

Data type

integer

Alias
Code-1
How many cigarettes per day do, or did, you smoke
UMLS CUI-1
C3169451
LOINC-1
MTHU037005
Alcohol consumption
Description

Alkohol

Data type

boolean

Alias
Code-1
Alcohol consumption
UMLS CUI-1
C0001948
SNOMED CT-1
160573003
MedDRA-1
10048921
Details of drinking behavior
Description

Alkohol

Data type

string

Alias
Code-1
Details of drinking behavior
UMLS CUI-1
C1285666
SNOMED CT-1
363905002
Family history
Data type

text

Alias
UMLS CUI-1
C0241889
Pre-existing Condition
Description

Pre-existing Condition

Pre-existing Condition
Description

Vorerkrankungen/Voroperationen

Data type

boolean

Alias
Code-1
Pre-existing Condition
UMLS CUI-1
C0521987
SNOMED CT-1
102478008
Thrombosis
Description

Thrombose

Data type

boolean

Alias
Code-1
Thrombosis
UMLS CUI-1
C0040053
SNOMED CT-1
439127006
MedDRA-1
10043607
Pre-existing Condition
Description

Erkrankungen/Operationen

Data type

string

Alias
Code-1
Pre-existing Condition
UMLS CUI-1
C0521987
SNOMED CT-1
102478008
Date pre-existing condition
Description

Datum/Jahr

Data type

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Pre-existing Condition
UMLS CUI-2
C0521987
SNOMED CT-2
102478008
therapy
Description

Therapie

Data type

string

Alias
Code-1
Therapeutic procedure
UMLS CUI-1
C0087111
SNOMED CT-1
277132007
MedDRA-1
10053757
LOINC-1
MTHU008880
Code-2
Pre-existing Condition
UMLS CUI-2
C0521987
SNOMED CT-2
102478008
External Result
Description

External Result

Mammography
Description

Mammografie

Data type

boolean

Alias
Code-1
Mammography
UMLS CUI-1
C0024671
SNOMED CT-1
71651007
MedDRA-1
10026735
Date Mammography
Description

Mammografie

Data type

date

Alias
Code-1
Mammography
UMLS CUI-1
C0024671
SNOMED CT-1
71651007
MedDRA-1
10026735
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
Site of finding
Description

Seite Befund

Data type

integer

Alias
Code-Info
for_compare
Code-1
Side
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Imaging, Medical
UMLS CUI-2
C0025086
BI-RADS mammo
Description

BIRADS

Data type

integer

Alias
Code-Info
merged_coding
Code-1
set of BI-RADS mammo terms
UMLS CUI-1
CL426926
Sonography
Description

Sonografie

Data type

boolean

Alias
Code-1
Ultrasonography, Mammary
UMLS CUI-1
C0080264
SNOMED CT-1
47079000
Date Sonography
Description

Sonografie

Data type

date

Alias
Code-1
Ultrasonography, Mammary
UMLS CUI-1
C0080264
SNOMED CT-1
47079000
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
BI-RADS ultrasound
Description

BIRADSanalog

Data type

integer

Alias
Code-Info
merged_coding
Code-1
set of BI-RADS ultrasound terms
UMLS CUI-1
CL426924
Magnetic Resonance Imaging of breast
Description

MR-MG

Data type

boolean

Alias
Code-1
Magnetic resonance imaging of breast (procedure)
UMLS CUI-1
C0344104
SNOMED CT-1
241615005
date Magnetic Resonance Imaging of breast
Description

MR-MG

Data type

date

Alias
Code-1
Magnetic resonance imaging of breast (procedure)
UMLS CUI-1
C0344104
SNOMED CT-1
241615005
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
BI-RADS MRI
Description

MR-BIRADS

Data type

integer

Alias
Code-1
set of BI-RADS MRI terms
UMLS CUI-1
CL426925
Histopathology
Description

Histologie

Data type

boolean

Alias
Code-1
Histopathology
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
other result
Description

Sonstiges

Data type

boolean

Alias
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Code-2
Result
UMLS CUI-2
C1274040
SNOMED CT-2
394617004
Physical Examination
Description

Physical Examination

Breast size
Description

Körbchengröße

Data type

integer

Alias
Code-1
Breast size (observable entity)
UMLS CUI-1
C0425782
SNOMED CT-1
248808008
Ptosis of breast
Description

Ptosis

Data type

integer

Alias
Code-1
Ptosis of breast
UMLS CUI-1
C2233848
ICD-10-CM-1
N64.81
ICD-9-CM-1
611.81
Symmetry
Description

Symmetrie

Data type

integer

Alias
Code-1
Symmetry of breasts (observable entity)
UMLS CUI-1
C0425778
nipple discharge
Description

Sekretion

Data type

integer

Alias
Code-1
nipple discharge
UMLS CUI-1
C0149741
SNOMED CT-1
54302000
MedDRA-1
10006223
LOINC-1
MTHU007943
ICD-10-CM-1
N64.52
Skin structure of breast
Description

Haut

Data type

integer

Alias
Code-1
Skin structure of breast
UMLS CUI-1
C0149538
SNOMED CT-1
82038008
Intradermal Node
Description

intradermale Knoten

Data type

boolean

Alias
Code-1
Intradermal
UMLS CUI-1
C0150647
Code-2
Node
UMLS CUI-2
C0746922
Inflammatory Breast Carcinoma
Description

inflammatorisch

Data type

boolean

Alias
Code-1
Inflammatory Breast Carcinoma
UMLS CUI-1
C0278601
SNOMED CT-1
254840009
MedDRA-1
10021980
Consistency of breast
Description

Brustkonsistenz

Data type

integer

Alias
Code-1
Consistency of breast (observable entity)
UMLS CUI-1
C1286084
SNOMED CT-1
364373009
Site of finding
Description

Seite Befund

Data type

integer

Alias
Code-Info
for_compare
Code-1
Side
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Finding
UMLS CUI-2
C1285578
SNOMED CT-2
363787002
Palpatory diagnosis
Description

auffälliger Tastbefund

Data type

integer

Alias
Code-Info
merged_coding
Code-1
Palpatory diagnosis (qualifier value)
UMLS CUI-1
C1562881
SNOMED CT-1
416400009
Code-2
Breast
UMLS CUI-2
C0006141
SNOMED CT-2
76752008
LOINC-2
MTHU011382
Count of entities
Description

Anzahl

Data type

string

Alias
Code-Info
merged_coding
Code-1
Count of entities (property) (qualifier value)
UMLS CUI-1
C0449788
SNOMED CT-1
410681005
Code-2
Palpatory diagnosis (qualifier value)
UMLS CUI-2
C1562881
SNOMED CT-2
416400009
Code-3
Breast
UMLS CUI-3
C0006141
SNOMED CT-3
76752008
LOINC-3
MTHU011382
Clockface position
Description

Uhr

Data type

integer

Alias
Code-Info
merged_coding
Code-1
Clockface position (qualifier value)
UMLS CUI-1
C0442310
SNOMED CT-1
272485000
Code-3
Clinical
UMLS CUI-3
C0205210
SNOMED CT-3
58147004
breast lump size
Description

Größe

Data type

integer

Alias
Code-Info
merged_coding
Code-1
On examination - breast lump size (finding
UMLS CUI-1
C0437115
SNOMED CT-1
163474006
Code-3
Clinical
UMLS CUI-3
C0205210
SNOMED CT-3
58147004
Suspected
Description

Suspekt

Data type

boolean

Alias
Code-Info
merged_coding
Code-1
Suspected
UMLS CUI-1
C0750491
SNOMED CT-1
415684004
Code-3
Clinical
UMLS CUI-3
C0205210
SNOMED CT-3
58147004
Site of lymph node
Description

Seite Lymphknoten

Data type

integer

Alias
Code-Info
for_compare
Code-1
Site of lymph node (observable entity)
UMLS CUI-1
C1302572
SNOMED CT-1
399635006
lymph nodes
Description

Lymphknoten

Data type

integer

Alias
Code-1
lymph nodes
UMLS CUI-1
C0024204
SNOMED CT-1
59441001
LOINC-1
MTHU015050
Code-2
Clinical
UMLS CUI-2
C0205210
SNOMED CT-2
58147004
drawing
Description

"Zeichnung klin."

Data type

string

Alias
Code-1
Drawings (art)
UMLS CUI-1
C0013113
Ultrasonography
Description

Ultrasonography

drawing sonography
Description

"Zeichnung Sono"

Data type

string

Alias
Code-1
Drawings (art)
UMLS CUI-1
C0013113
Code-2
Ultrasonography, Mammary
UMLS CUI-2
C0080264
SNOMED CT-2
47079000
HL7 V3-2
12
Site of sonography
Description

Seite Sono

Data type

integer

Alias
Code-Info
for_compare
Code-1
Side
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Ultrasonography, Mammary
UMLS CUI-2
C0080264
SNOMED CT-2
47079000
Numbers
Description

Nr.

Data type

integer

Alias
Code-1
Numbers
UMLS CUI-1
C0237753
SNOMED CT-1
260299005
LOINC-1
MTHU024869
Clockface position
Description

Uhr

Data type

integer

Alias
Code-1
Clockface position (qualifier value)
UMLS CUI-1
C0442310
SNOMED CT-1
272485000
Code-2
Ultrasonography, Mammary
UMLS CUI-2
C0080264
SNOMED CT-2
47079000
HL7 V3-2
12
size
Description

Metrik

Data type

string

Alias
Code-1
Lesion size (observable entity)
UMLS CUI-1
C0449453
SNOMED CT-1
246116008
Code-2
Ultrasonography, Mammary
UMLS CUI-2
C0080264
SNOMED CT-2
47079000
BI-RADS ultrasound
Description

Dignität (BIRADS I-V)

Data type

string

Alias
Code-1
set of BI-RADS ultrasound terms
UMLS CUI-1
CL426924
lymph nodes
Description

Lymphknoten

Data type

integer

Alias
Code-1
lymph nodes
UMLS CUI-1
C0024204
SNOMED CT-1
59441001
LOINC-1
MTHU015050
Code-2
Ultrasonography, Mammary
UMLS CUI-2
C0080264
SNOMED CT-2
47079000
HL7 V3-2
12
Lesion number
Description

Target Nr.

Data type

integer

Alias
Code-1
Lesion Number
UMLS CUI-1
C0449791
SNOMED CT-1
246206008
Side Lesion
Description

Seite Läsion

Data type

integer

Alias
Code-Info
for_compare
Code-1
Side
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Lesion
UMLS CUI-2
C0221198
SNOMED CT-2
49755003
Form
Description

Form

Data type

integer

Alias
Code-1
Form (attribute)
UMLS CUI-1
C0348078
SNOMED CT-1
246176004
Code-2
Lesion
UMLS CUI-2
C0221198
SNOMED CT-2
49755003
Axis
Description

Achse

Data type

integer

Alias
Code-1
Axis
UMLS CUI-1
C1522496
Margin
Description

Begrenzung

Data type

integer

Alias
Code-Info
merged_coding
Code-1
Margin
UMLS CUI-1
C0205284
SNOMED CT-1
112233002
Code-2
Ultrasonography, Mammary
UMLS CUI-2
C0080264
SNOMED CT-2
47079000
HL7 V3-2
12
echogenicity
Description

Echogenität

Data type

integer

Alias
Code-1
Ultrasonographic echogenicity (observable entity)
UMLS CUI-1
C1719852
SNOMED CT-1
421222001
echotexture
Description

Echostruktur

Data type

integer

Alias
Code-1
echotexture
UMLS CUI-1
CL427892
posterior acoustic enhancement
Description

zentrale Schalverstärkung

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
posterior acoustic enhancement
UMLS CUI-1
CL427825
posterior acoustic shadowing
Description

Zentralschatten

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
posterior acoustic shadowing
UMLS CUI-1
CL427967
Acoustic shadowing unilateral
Description

unilat. Schallauslöschung

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Acoustic shadowing of mass (observable entity)
UMLS CUI-1
C1719833
SNOMED CT-1
420527001
Code-2
Unilateral
UMLS CUI-2
C0205092
SNOMED CT-2
66459002
Acoustic shadowing bilateral
Description

bilaterale Schallauslöschung

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Acoustic shadowing of mass (observable entity)
UMLS CUI-1
C1719833
SNOMED CT-1
420527001
Code-2
Bilateral
UMLS CUI-2
C0238767
SNOMED CT-2
51440002
not_coded
Description

Destruktionsphänomen

Data type

integer

not_coded
Description

Komprimierbarkeit

Data type

integer

Vessels
Description

Gefäße

Data type

integer

Alias
Code-1
Blood Vessels
UMLS CUI-1
C0005847
SNOMED CT-1
59820001
LOINC-1
MTHU001441
Biopsy
Description

Biopsie/Punktion durchgeführt

Data type

boolean

Alias
Code-1
Biopsy
UMLS CUI-1
C0005558
SNOMED CT-1
86273004
MedDRA-1
10004720
LOINC-1
MTHU028106
Ultrasound-guided Biopsy
Description

Ultraschallgestütze Stanzbiopsie

Data type

boolean

Alias
Code-1
Ultrasound-guided Biopsy
UMLS CUI-1
C0456900
SNOMED CT-1
277667006
Puncture of cyst
Description

Cystenpunktion

Data type

boolean

Alias
Code-1
Puncture and aspiration of cyst (procedure)
UMLS CUI-1
C2733030
SNOMED CT-1
443803004
Lesion number
Description

Herdbefund Nr.

Data type

integer

Alias
Code-1
Lesion Number
UMLS CUI-1
C0449791
SNOMED CT-1
246206008
count of Punches
Description

Anzahl der Stanzen

Data type

integer

Alias
Code-1
Punch biopsy (procedure)
UMLS CUI-1
C0184924
SNOMED CT-1
68660007
Code-2
Count of entities (property) (qualifier value)
UMLS CUI-2
C0449788
SNOMED CT-2
410681005
not_coded
Description

Herd nach Stanze verändert

Data type

integer

Photo documentation
Description

Fotodokumentation

Data type

boolean

Alias
Code-1
Photo documentation
UMLS CUI-1
C0946283
LOINC-1
MTHU013840
Date
Description

Datum

Data type

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Signature of responsible attending physician on file
UMLS CUI-2
C0807938
signature
Description

Unterschrift

Data type

string

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

procedures

additional medical imaging
Description

Weiterführende Bildgebung

Data type

boolean

Alias
Code-1
Additional
UMLS CUI-1
C1524062
LOINC-1
MTHU013802
Code-2
Imaging, Medical
UMLS CUI-2
C0025086
Mammography
Description

Mammografie

Data type

boolean

Alias
UMLS CUI-1
C0024671
SNOMED CT-1
71651007
MedDRA-1
10026735
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
date Mammography
Description

Mammografie

Data type

date

Alias
UMLS CUI-1
C0024671
SNOMED CT-1
71651007
MedDRA-1
10026735
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
Ultrasonography
Description

Sonografie

Data type

boolean

Alias
Code-1
Ultrasonography, Mammary
UMLS CUI-1
C0080264
SNOMED CT-1
47079000
HL7 V3-1
12
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
date Ultrasonography
Description

Sonografie

Data type

date

Alias
Code-1
Ultrasonography, Mammary
UMLS CUI-1
C0080264
SNOMED CT-1
47079000
HL7 V3-1
12
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
other medical imaging
Description

Sonstige

Data type

boolean

Alias
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Code-2
Imaging, Medical
UMLS CUI-2
C0025086
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
date other medical imaging
Description

Sonstige

Data type

date

Alias
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Code-2
Imaging, Medical
UMLS CUI-2
C0025086
Code-3
Date in time
UMLS CUI-3
C0011008
SNOMED CT-3
410671006
LOINC-3
MTHU021546
cancer conference
Description

Anmeldung TuKo

Data type

boolean

Alias
Code-1
Registration
UMLS CUI-1
C1514821
Code-2
Cancer conference
UMLS CUI-2
C0805438
Date cancer conference
Description

TuKo

Data type

date

Alias
Code-1
Cancer conference:Time Stamp -- Date and Time:Point in time:Cancer.To be specified in another part of the message:Quantitative
UMLS CUI-1
C0804663
LOINC-1
21875-0
Aftercare
Description

reguläre weitere Vorsorge

Data type

boolean

Alias
UMLS CUI-1
C0001758
SNOMED CT-1
413467001
Follow-Up
Description

Wiedervorstellung

Data type

boolean

Alias
Code-1
Follow-up visit (procedure)
UMLS CUI-1
C0589121
SNOMED CT-1
185389009
Date Follow-Up
Description

Wiedervorstellung

Data type

date

Alias
Code-1
Follow-up visit (procedure)
UMLS CUI-1
C0589121
SNOMED CT-1
185389009
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
free text
Description

Freitext

Data type

string

Alias
Code-1
Free Text Format
UMLS CUI-1
C2348713
Date
Description

Datum

Data type

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Signature of responsible attending physician on file
UMLS CUI-2
C0807938
signature
Description

Unterschrift

Data type

string

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

EHR breast cancer

1 forms
  1. StudyEvent: HIS
    1. EHR breast cancer
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patientenaufkleber groß
C1320722 (UMLS CUI-1)
Admission date
Item
Admission date
date
Date of admission (Code-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
C1302393 (UMLS CUI-1)
Patient ID
Item
Patient Identification Number
integer
Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal (Code-1)
52463-7 (LOINC-1)
C2706086 (UMLS CUI-1)
Gender
Item
Patient sex
text
184100006 (SNOMED CT-1)
C0150831 (UMLS CUI-1)
Last name
Item
Patient surname
text
184096005 (SNOMED CT-1)
C1301584 (UMLS CUI-1)
First name
Item
Patient forename
text
184095009 (SNOMED CT-1)
C1443235 (UMLS CUI-1)
Date of Birth
Item
Patient date of birth
date
184099003 (SNOMED CT-1)
C0421451 (UMLS CUI-1)
Admission time
Item
Admission hour
time
Date of admission (Code-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
Hour (Code-2)
258702006 (SNOMED CT-2)
HR (HL7 V3-2)
C2215405 (UMLS CUI-1)
Referring physician
Item
Physician admission
text
Admission (Code-1)
Physicians (Code-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
PHYS (HL7 V3-2)
C1709880 (UMLS CUI-1)
Assessment date
Item
date
C2985720 (UMLS CUI-1)
Item Group
Anamnesebogen
C0262926 (UMLS CUI-1)
Anamnese erhoben durch
Item
Responsible Person for medical case
string
Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
Medical History (Code-2)
C0262926 (UMLS CUI-2)
417662000 (SNOMED CT-2)
MTHU027722 (LOINC-2)
Zuweisender Arzt
Item
Referring Physician
string
Referring Physician (Code-1)
C1709880 (UMLS CUI-1)
FFA
Item
Gynecologist
string
Gynecologist (Code-1)
C0237419 (UMLS CUI-1)
83685006 (SNOMED CT-1)
207VG0400X (HL7 V3-1)
Überweisungsgrund
Item
Reason for Referring
string
Referring (Code-1)
C0205543 (UMLS CUI-1)
Indication of (contextual qualifier) (Code-2)
C0392360 (UMLS CUI-2)
410666004 (SNOMED CT-2)
MTHU008862 (LOINC-2)
Item
Reason for patient visit
integer
Reason for patient visit (Code-1)
C1704447 (UMLS CUI-1)
103324002 (SNOMED CT-1)
MTHU013910 (LOINC-1)
Grund des Arztbesuches
Code List
Reason for patient visit
CL Item
Secondary Prevention  (Vorsorge)
Secondary Prevention (Code-1)
C0679699 (UMLS CUI-1)
315234002 (SNOMED CT-1)
10067625 (MedDRA-1)
CL Item
Incidental Finding (Zufallsbefund)
Incidental Finding (Code-1)
C0743997 (UMLS CUI-1)
CL Item
Aftercare (Nachsorge)
Aftercare (Code-1)
C0001758 (UMLS CUI-1)
413467001 (SNOMED CT-1)
CL Item
Symptoms (Symptomatik)
Symptoms (Code-1)
C1457887 (UMLS CUI-1)
MTHU021540 (LOINC-1)
780-789,99 (ICD-9-CM-1)
CL Item
Self-Examination  (Selbstuntersuchung)
C0080142 (UMLS CUI-1)
409978001 (SNOMED CT-1)
CL Item
Screening procedure (Screening)
C0220908 (UMLS CUI-1)
275926002 (SNOMED CT-1)
Anamnese
Item
Medical History
string
Medical History (Code-1)
C0262926 (UMLS CUI-1)
417662000 (SNOMED CT-1)
MTHU027722 (LOINC-1)
Item
Menopause Status
integer
Menopause finding (finding) (Code-1)
C0455962 (UMLS CUI-1)
276477006 (SNOMED CT-1)
Menopausenstatus
Code List
Menopause Status
CL Item
Premenopause (Prämenopause)
Premenopausal state (finding) (Code-1)
C0232969 (UMLS CUI-1)
22636003 (SNOMED CT-1)
CL Item
Postmenopause (Postmenopause)
Postmenopausal (Code-1)
C0232970 (UMLS CUI-1)
76498008 (SNOMED CT-1)
CL Item
Perimenopause (peripausal)
C0993589 (UMLS CUI-1)
198435007 (SNOMED CT-1)
10062974 (MedDRA-1)
CL Item
unknown Menopause finding (unbekannt)
Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
Schwangerschaften
Item
quantity of pregnancy
integer
Finding of quantity of pregnancy (finding) (Code-1)
C0566634 (UMLS CUI-1)
289204008 (SNOMED CT-1)
Stillzeit (Monate)
Item
Months of breast feeding
integer
Months of breast feeding (Code-1)
C3172259 (UMLS CUI-1)
Akuelle Medikamente
Item
Drugs
integer
Pharmaceutical Preparations (Code-1)
C0013227 (UMLS CUI-1)
410942007 (SNOMED CT-1)
Pille
Item
Contraceptives
boolean
Contraceptives, Oral (Code-1)
C0009905 (UMLS CUI-1)
423938009 (SNOMED CT-1)
HRT
Item
Hormone replacement therapy
boolean
Hormone replacement therapy (Code-1)
C0282402 (UMLS CUI-1)
266717002 (SNOMED CT-1)
10020388 (MedDRA-1)
ASS
Item
Aspirin
boolean
Aspirin (Code-1)
C0004057 (UMLS CUI-1)
387458008 (SNOMED CT-1)
Marcumar
Item
Phenprocoumon
boolean
Phenprocoumon (Code-1)
C0031444 (UMLS CUI-1)
59488002 (SNOMED CT-1)
MTHU016364 (LOINC-1)
Allergien
Item
Allergic Reaction
string
Allergic Reaction (Code-1)
C1527304 (UMLS CUI-1)
106190000 (SNOMED CT-1)
10020751 (MedDRA-1)
T78.40 (ICD-10-CM-1)
E11248 (CTCAE-1)
ALG (HL7 V3-1)
Nikotin
Item
Tobacco smoking
boolean
Tobacco smoking behavior (Code-1)
C0453996 (UMLS CUI-1)
365981007 (SNOMED CT-1)
Zig./die
Item
How many cigarettes per day do, or did, you smoke
integer
How many cigarettes per day do, or did, you smoke (Code-1)
C3169451 (UMLS CUI-1)
MTHU037005 (LOINC-1)
Alkohol
Item
Alcohol consumption
boolean
Alcohol consumption (Code-1)
C0001948 (UMLS CUI-1)
160573003 (SNOMED CT-1)
10048921 (MedDRA-1)
Alkohol
Item
Details of drinking behavior
string
Details of drinking behavior (Code-1)
C1285666 (UMLS CUI-1)
363905002 (SNOMED CT-1)
Family history
Item
text
C0241889 (UMLS CUI-1)
Item Group
Pre-existing Condition
Vorerkrankungen/Voroperationen
Item
Pre-existing Condition
boolean
Pre-existing Condition (Code-1)
C0521987 (UMLS CUI-1)
102478008 (SNOMED CT-1)
Thrombose
Item
Thrombosis
boolean
Thrombosis (Code-1)
C0040053 (UMLS CUI-1)
439127006 (SNOMED CT-1)
10043607 (MedDRA-1)
Erkrankungen/Operationen
Item
Pre-existing Condition
string
Pre-existing Condition (Code-1)
C0521987 (UMLS CUI-1)
102478008 (SNOMED CT-1)
Datum/Jahr
Item
Date pre-existing condition
date
Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Pre-existing Condition (Code-2)
C0521987 (UMLS CUI-2)
102478008 (SNOMED CT-2)
Therapie
Item
therapy
string
Therapeutic procedure (Code-1)
C0087111 (UMLS CUI-1)
277132007 (SNOMED CT-1)
10053757 (MedDRA-1)
MTHU008880 (LOINC-1)
Pre-existing Condition (Code-2)
C0521987 (UMLS CUI-2)
102478008 (SNOMED CT-2)
Item Group
External Result
Mammografie
Item
Mammography
boolean
Mammography (Code-1)
C0024671 (UMLS CUI-1)
71651007 (SNOMED CT-1)
10026735 (MedDRA-1)
Mammografie
Item
Date Mammography
date
Mammography (Code-1)
C0024671 (UMLS CUI-1)
71651007 (SNOMED CT-1)
10026735 (MedDRA-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Item
Site of finding
integer
for_compare (Code-Info)
Side (Code-1)
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Imaging, Medical (Code-2)
C0025086 (UMLS CUI-2)
Seite Befund
Code List
Site of finding
CL Item
right (rechts)
for_compare (Code-Info)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
left (links)
for_compare (Code-Info)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
BIRADS
Item
BI-RADS mammo
integer
merged_coding (Code-Info)
set of BI-RADS mammo terms (Code-1)
CL426926 (UMLS CUI-1)
Sonografie
Item
Sonography
boolean
Ultrasonography, Mammary (Code-1)
C0080264 (UMLS CUI-1)
47079000 (SNOMED CT-1)
Sonografie
Item
Date Sonography
date
Ultrasonography, Mammary (Code-1)
C0080264 (UMLS CUI-1)
47079000 (SNOMED CT-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
BIRADSanalog
Item
BI-RADS ultrasound
integer
merged_coding (Code-Info)
set of BI-RADS ultrasound terms (Code-1)
CL426924 (UMLS CUI-1)
MR-MG
Item
Magnetic Resonance Imaging of breast
boolean
Magnetic resonance imaging of breast (procedure) (Code-1)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
MR-MG
Item
date Magnetic Resonance Imaging of breast
date
Magnetic resonance imaging of breast (procedure) (Code-1)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
MR-BIRADS
Item
BI-RADS MRI
integer
set of BI-RADS MRI terms (Code-1)
CL426925 (UMLS CUI-1)
Histologie
Item
Histopathology
boolean
Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Sonstiges
Item
other result
boolean
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Result (Code-2)
C1274040 (UMLS CUI-2)
394617004 (SNOMED CT-2)
Item Group
Physical Examination
Item
Breast size
integer
Breast size (observable entity) (Code-1)
C0425782 (UMLS CUI-1)
248808008 (SNOMED CT-1)
Körbchengröße
Code List
Breast size
CL Item
not_coded (A)
CL Item
not_coded (B)
CL Item
not_coded (C)
CL Item
not_coded (D)
CL Item
not_coded (> D)
Item
Ptosis of breast
integer
Ptosis of breast (Code-1)
C2233848 (UMLS CUI-1)
N64.81 (ICD-10-CM-1)
611.81 (ICD-9-CM-1)
Ptosis
Code List
Ptosis of breast
CL Item
None (keine)
None (Code-1)
C0549184 (UMLS CUI-1)
260413007 (SNOMED CT-1)
CL Item
medium (mittel)
Medium (Code-1)
C0439536 (UMLS CUI-1)
255508009 (SNOMED CT-1)
CL Item
marked (ausgeprägt)
Massive (qualifier value) (Code-1)
C0522501 (UMLS CUI-1)
46998006 (SNOMED CT-1)
Item
Symmetry
integer
Symmetry of breasts (observable entity) (Code-1)
C0425778 (UMLS CUI-1)
Symmetrie
Code List
Symmetry
CL Item
symmetry of breasts (ja)
Finding of symmetry of breasts (finding) (Code-1)
C1287869 (UMLS CUI-1)
366348007 (SNOMED CT-1)
CL Item
breast asymmetry (nein)
On examination - breast asymmetry (finding) (Code-1)
C0437091 (UMLS CUI-1)
163438002 (SNOMED CT-1)
CL Item
no: li>re (nein: li>re)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Greater (Code-2)
C1704243 (UMLS CUI-2)
263768009 (SNOMED CT-2)
Right (Code-3)
C0205090 (UMLS CUI-3)
24028007 (SNOMED CT-3)
CL Item
no: li<re (nein: li<re)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Lesser (Code-2)
C0547044 (UMLS CUI-2)
263796003 (SNOMED CT-2)
Right (Code-3)
C0205090 (UMLS CUI-3)
24028007 (SNOMED CT-3)
Item
nipple discharge
integer
nipple discharge (Code-1)
C0149741 (UMLS CUI-1)
54302000 (SNOMED CT-1)
10006223 (MedDRA-1)
MTHU007943 (LOINC-1)
N64.52 (ICD-10-CM-1)
Sekretion
Code List
nipple discharge
CL Item
No nipple discharge  (nein)
No nipple discharge (finding) (Code-1)
C0425813 (UMLS CUI-1)
162165008 (SNOMED CT-1)
CL Item
Nipple discharge present  (ja)
Nipple discharge present (disorder) (Code-1)
C0425812 (UMLS CUI-1)
162166009 (SNOMED CT-1)
CL Item
Serosanguineous nipple discharge  (ja: blutig)
Serosanguineous nipple discharge (disorder (Code-1)
C0567521 (UMLS CUI-1)
290110007 (SNOMED CT-1)
CL Item
Serous nipple discharge (ja: serös)
Serous nipple discharge (disorder) (Code-1)
C0567520 (UMLS CUI-1)
290109002 (SNOMED CT-1)
CL Item
Milky nipple discharge  (ja: milchig)
Milky nipple discharge (disorder) (Code-1)
C0567523 (UMLS CUI-1)
290112004 (SNOMED CT-1)
Item
Skin structure of breast
integer
Skin structure of breast (Code-1)
C0149538 (UMLS CUI-1)
82038008 (SNOMED CT-1)
Haut
Code List
Skin structure of breast
CL Item
Normal (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
skin retraction (Einziehung)
skin retraction (Code-1)
CL427939 (UMLS CUI-1)
CL Item
plateau (Plateau)
plateau (Code-1)
CL427821 (UMLS CUI-1)
CL Item
breast edema (Ödem)
BREAST EDEMA (Code-1)
C0235649 (UMLS CUI-1)
290077003 (SNOMED CT-1)
10006294 (MedDRA-1)
CL Item
Ulceration of breast  (Ulzeration)
Ulceration of breast (finding) (Code-1)
C0425793 (UMLS CUI-1)
248818003 (SNOMED CT-1)
intradermale Knoten
Item
Intradermal Node
boolean
Intradermal (Code-1)
C0150647 (UMLS CUI-1)
Node (Code-2)
C0746922 (UMLS CUI-2)
inflammatorisch
Item
Inflammatory Breast Carcinoma
boolean
Inflammatory Breast Carcinoma (Code-1)
C0278601 (UMLS CUI-1)
254840009 (SNOMED CT-1)
10021980 (MedDRA-1)
Item
Consistency of breast
integer
Consistency of breast (observable entity) (Code-1)
C1286084 (UMLS CUI-1)
364373009 (SNOMED CT-1)
Brustkonsistenz
Code List
Consistency of breast
CL Item
Normal breast consistency (weich, gut beurteilbar)
Normal breast consistency (finding) (Code-1)
C0567480 (UMLS CUI-1)
290063001 (SNOMED CT-1)
CL Item
breast lump consistency (knotig, schwer beurteilbar)
On examination - breast lump consistency (finding) (Code-1)
C0437122 (UMLS CUI-1)
163482006 (SNOMED CT-1)
Item
Site of finding
integer
for_compare (Code-Info)
Side (Code-1)
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Finding (Code-2)
C1285578 (UMLS CUI-2)
363787002 (SNOMED CT-2)
Seite Befund
Code List
Site of finding
CL Item
right (rechts)
for_compare (Code-Info)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
left (links)
for_compare (Code-Info)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Item
Palpatory diagnosis
integer
merged_coding (Code-Info)
Palpatory diagnosis (qualifier value) (Code-1)
C1562881 (UMLS CUI-1)
416400009 (SNOMED CT-1)
Breast (Code-2)
C0006141 (UMLS CUI-2)
76752008 (SNOMED CT-2)
MTHU011382 (LOINC-2)
auffälliger Tastbefund
Code List
Palpatory diagnosis
CL Item
No (nein (nonpalpabel))
No (Code-1)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Single  (solitär)
Single (Code-1)
C0205171 (UMLS CUI-1)
50607009 (SNOMED CT-1)
CL Item
Multiple (multiple)
Multiple (Code-1)
C0439064 (UMLS CUI-1)
255204007 (SNOMED CT-1)
Anzahl
Item
Count of entities
string
merged_coding (Code-Info)
Count of entities (property) (qualifier value) (Code-1)
C0449788 (UMLS CUI-1)
410681005 (SNOMED CT-1)
Palpatory diagnosis (qualifier value) (Code-2)
C1562881 (UMLS CUI-2)
416400009 (SNOMED CT-2)
Breast (Code-3)
C0006141 (UMLS CUI-3)
76752008 (SNOMED CT-3)
MTHU011382 (LOINC-3)
Uhr
Item
Clockface position
integer
merged_coding (Code-Info)
Clockface position (qualifier value) (Code-1)
C0442310 (UMLS CUI-1)
272485000 (SNOMED CT-1)
Clinical (Code-3)
C0205210 (UMLS CUI-3)
58147004 (SNOMED CT-3)
Größe
Item
breast lump size
integer
merged_coding (Code-Info)
On examination - breast lump size (finding (Code-1)
C0437115 (UMLS CUI-1)
163474006 (SNOMED CT-1)
Clinical (Code-3)
C0205210 (UMLS CUI-3)
58147004 (SNOMED CT-3)
Suspekt
Item
Suspected
boolean
merged_coding (Code-Info)
Suspected (Code-1)
C0750491 (UMLS CUI-1)
415684004 (SNOMED CT-1)
Clinical (Code-3)
C0205210 (UMLS CUI-3)
58147004 (SNOMED CT-3)
Item
Site of lymph node
integer
for_compare (Code-Info)
Site of lymph node (observable entity) (Code-1)
C1302572 (UMLS CUI-1)
399635006 (SNOMED CT-1)
Seite Lymphknoten
Code List
Site of lymph node
CL Item
right (rechts)
for_compare (Code-Info)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
left (links)
for_compare (Code-Info)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Item
lymph nodes
integer
lymph nodes (Code-1)
C0024204 (UMLS CUI-1)
59441001 (SNOMED CT-1)
MTHU015050 (LOINC-1)
Clinical (Code-2)
C0205210 (UMLS CUI-2)
58147004 (SNOMED CT-2)
Lymphknoten
Code List
lymph nodes
CL Item
Negation  (nicht tastbar)
Negation (Code-1)
C1518423 (UMLS CUI-1)
Palpable (Code-2)
C0522499 (UMLS CUI-2)
103357000 (SNOMED CT-2)
CL Item
Palpable (tastbar)
Palpable (Code-1)
C0522499 (UMLS CUI-1)
103357000 (SNOMED CT-1)
CL Item
Suspected (suspekt)
Suspected (Code-1)
C0750491 (UMLS CUI-1)
415684004 (SNOMED CT-1)
"Zeichnung klin."
Item
drawing
string
Drawings (art) (Code-1)
C0013113 (UMLS CUI-1)
Item Group
Ultrasonography
"Zeichnung Sono"
Item
drawing sonography
string
Drawings (art) (Code-1)
C0013113 (UMLS CUI-1)
Ultrasonography, Mammary (Code-2)
C0080264 (UMLS CUI-2)
47079000 (SNOMED CT-2)
12 (HL7 V3-2)
Item
Site of sonography
integer
for_compare (Code-Info)
Side (Code-1)
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Ultrasonography, Mammary (Code-2)
C0080264 (UMLS CUI-2)
47079000 (SNOMED CT-2)
Seite Sono
Code List
Site of sonography
CL Item
right (rechts)
for_compare (Code-Info)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
left (links)
for_compare (Code-Info)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Nr.
Item
Numbers
integer
Numbers (Code-1)
C0237753 (UMLS CUI-1)
260299005 (SNOMED CT-1)
MTHU024869 (LOINC-1)
Uhr
Item
Clockface position
integer
Clockface position (qualifier value) (Code-1)
C0442310 (UMLS CUI-1)
272485000 (SNOMED CT-1)
Ultrasonography, Mammary (Code-2)
C0080264 (UMLS CUI-2)
47079000 (SNOMED CT-2)
12 (HL7 V3-2)
Metrik
Item
size
string
Lesion size (observable entity) (Code-1)
C0449453 (UMLS CUI-1)
246116008 (SNOMED CT-1)
Ultrasonography, Mammary (Code-2)
C0080264 (UMLS CUI-2)
47079000 (SNOMED CT-2)
Dignität (BIRADS I-V)
Item
BI-RADS ultrasound
string
set of BI-RADS ultrasound terms (Code-1)
CL426924 (UMLS CUI-1)
Item
lymph nodes
integer
lymph nodes (Code-1)
C0024204 (UMLS CUI-1)
59441001 (SNOMED CT-1)
MTHU015050 (LOINC-1)
Ultrasonography, Mammary (Code-2)
C0080264 (UMLS CUI-2)
47079000 (SNOMED CT-2)
12 (HL7 V3-2)
Lymphknoten
Code List
lymph nodes
CL Item
Normal (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
Suspected (suspekt)
Suspected (Code-1)
C0750491 (UMLS CUI-1)
415684004 (SNOMED CT-1)
CL Item
Pathologic (pathologisch)
Pathologic (Code-1)
C1521733 (UMLS CUI-1)
29458008 (SNOMED CT-1)
Target Nr.
Item
Lesion number
integer
Lesion Number (Code-1)
C0449791 (UMLS CUI-1)
246206008 (SNOMED CT-1)
Item
Side Lesion
integer
for_compare (Code-Info)
Side (Code-1)
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Lesion (Code-2)
C0221198 (UMLS CUI-2)
49755003 (SNOMED CT-2)
Seite Läsion
Code List
Side Lesion
CL Item
Right (rechts)
changed_datatype (Code-Info)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
Left (links)
changed_datatype (Code-Info)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Item
Form
integer
Form (attribute) (Code-1)
C0348078 (UMLS CUI-1)
246176004 (SNOMED CT-1)
Lesion (Code-2)
C0221198 (UMLS CUI-2)
49755003 (SNOMED CT-2)
Form
Code List
Form
CL Item
Round (rund)
Round (Code-1)
C0332490 (UMLS CUI-1)
42700002 (SNOMED CT-1)
CL Item
Oval (oval)
Oval (Code-1)
C1709367 (UMLS CUI-1)
CL Item
Complex (komplex)
Complex (Code-1)
C0439855 (UMLS CUI-1)
103360007 (SNOMED CT-1)
Item
Axis
integer
Axis (Code-1)
C1522496 (UMLS CUI-1)
Achse
Code List
Axis
CL Item
Horizontal (horizontal)
Horizontal (Code-1)
C0205126 (UMLS CUI-1)
24020000 (SNOMED CT-1)
CL Item
Vertical (vertikal)
Vertical (Code-1)
C0205128 (UMLS CUI-1)
33096000 (SNOMED CT-1)
CL Item
Indifferent (indifferent)
Indifferent (qualifier value (Code-1)
C0332238 (UMLS CUI-1)
54328002 (SNOMED CT-1)
Item
Margin
integer
merged_coding (Code-Info)
Margin (Code-1)
C0205284 (UMLS CUI-1)
112233002 (SNOMED CT-1)
Ultrasonography, Mammary (Code-2)
C0080264 (UMLS CUI-2)
47079000 (SNOMED CT-2)
12 (HL7 V3-2)
Begrenzung
Code List
Margin
CL Item
Smooth  (glatt)
Smooth (Code-1)
C0205357 (UMLS CUI-1)
82280004 (SNOMED CT-1)
CL Item
irregular (gezackt)
Irregular (Code-1)
C0205271 (UMLS CUI-1)
49608001 (SNOMED CT-1)
CL Item
circumscribed  (scharf)
circumscribed margin (Code-1)
CL381530 (UMLS CUI-1)
CL Item
Diffuse (unscharf)
Diffuse (Code-1)
C0205219 (UMLS CUI-1)
19648000 (SNOMED CT-1)
CL Item
echogenic halo (echoreicher Saum)
echogenic halo (Code-1)
CL427901 (UMLS CUI-1)
Item
echogenicity
integer
Ultrasonographic echogenicity (observable entity) (Code-1)
C1719852 (UMLS CUI-1)
421222001 (SNOMED CT-1)
Echogenität
Code List
echogenicity
CL Item
isoechoic (echogleich)
isoechoic (Code-1)
CL381581 (UMLS CUI-1)
CL Item
hypoechoic (echoarm)
hypoechoic (Code-1)
CL381580 (UMLS CUI-1)
CL Item
hyperechoic  (echoreich)
hyperechoic (Code-1)
CL381582 (UMLS CUI-1)
CL Item
anechoic (echoleer)
anechoic (Code-1)
CL427829 (UMLS CUI-1)
Item
echotexture
integer
echotexture (Code-1)
CL427892 (UMLS CUI-1)
Echostruktur
Code List
echotexture
CL Item
homogenous (homogen)
Homogeneity (Code-1)
C1881065 (UMLS CUI-1)
CL Item
heterogenous (inhomogen)
Heterogenous (Code-1)
C1512426 (UMLS CUI-1)
zentrale Schalverstärkung
Item
posterior acoustic enhancement
boolean
changed_datatype (Code-Info)
posterior acoustic enhancement (Code-1)
CL427825 (UMLS CUI-1)
Zentralschatten
Item
posterior acoustic shadowing
boolean
changed_datatype (Code-Info)
posterior acoustic shadowing (Code-1)
CL427967 (UMLS CUI-1)
unilat. Schallauslöschung
Item
Acoustic shadowing unilateral
boolean
changed_datatype (Code-Info)
Acoustic shadowing of mass (observable entity) (Code-1)
C1719833 (UMLS CUI-1)
420527001 (SNOMED CT-1)
Unilateral (Code-2)
C0205092 (UMLS CUI-2)
66459002 (SNOMED CT-2)
bilaterale Schallauslöschung
Item
Acoustic shadowing bilateral
boolean
changed_datatype (Code-Info)
Acoustic shadowing of mass (observable entity) (Code-1)
C1719833 (UMLS CUI-1)
420527001 (SNOMED CT-1)
Bilateral (Code-2)
C0238767 (UMLS CUI-2)
51440002 (SNOMED CT-2)
Item
not_coded
integer
Destruktionsphänomen
Code List
not_coded
CL Item
not_coded (Umgebungsarchitektur verdrängt)
CL Item
not_coded (unterbrochen)
Item
not_coded
integer
Komprimierbarkeit
Code List
not_coded
CL Item
not_coded (gut)
CL Item
not_coded (gering)
CL Item
not_coded (fehlend)
Item
Vessels
integer
Blood Vessels (Code-1)
C0005847 (UMLS CUI-1)
59820001 (SNOMED CT-1)
MTHU001441 (LOINC-1)
Gefäße
Code List
Vessels
CL Item
no vessels (keine Gefäße)
None (Code-1)
C0549184 (UMLS CUI-1)
260413007 (SNOMED CT-1)
CL Item
within tumor (im Tumor)
Malignant Neoplasms (Code-1)
C0006826 (UMLS CUI-1)
363346000 (SNOMED CT-1)
10007050 (MedDRA-1)
MTHU010328 (LOINC-1)
C80 (ICD-10-CM-1)
199 (ICD-9-CM-1)
Within (Code-2)
C0332285 (UMLS CUI-2)
18720000 (SNOMED CT-2)
CL Item
within enviroment (in Umgebung)
Environment (Code-1)
C0014406 (UMLS CUI-1)
276339004 (SNOMED CT-1)
MTHU009317 (LOINC-1)
Within (Code-2)
C0332285 (UMLS CUI-2)
18720000 (SNOMED CT-2)
Biopsie/Punktion durchgeführt
Item
Biopsy
boolean
Biopsy (Code-1)
C0005558 (UMLS CUI-1)
86273004 (SNOMED CT-1)
10004720 (MedDRA-1)
MTHU028106 (LOINC-1)
Ultraschallgestütze Stanzbiopsie
Item
Ultrasound-guided Biopsy
boolean
Ultrasound-guided Biopsy (Code-1)
C0456900 (UMLS CUI-1)
277667006 (SNOMED CT-1)
Cystenpunktion
Item
Puncture of cyst
boolean
Puncture and aspiration of cyst (procedure) (Code-1)
C2733030 (UMLS CUI-1)
443803004 (SNOMED CT-1)
Herdbefund Nr.
Item
Lesion number
integer
Lesion Number (Code-1)
C0449791 (UMLS CUI-1)
246206008 (SNOMED CT-1)
Anzahl der Stanzen
Item
count of Punches
integer
Punch biopsy (procedure) (Code-1)
C0184924 (UMLS CUI-1)
68660007 (SNOMED CT-1)
Count of entities (property) (qualifier value) (Code-2)
C0449788 (UMLS CUI-2)
410681005 (SNOMED CT-2)
Item
not_coded
integer
Herd nach Stanze verändert
Code List
not_coded
CL Item
not_coded (nein)
CL Item
not_coded (kleiner)
CL Item
not_coded (weg)
Fotodokumentation
Item
Photo documentation
boolean
Photo documentation (Code-1)
C0946283 (UMLS CUI-1)
MTHU013840 (LOINC-1)
Datum
Item
Date
date
Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Signature of responsible attending physician on file (Code-2)
C0807938 (UMLS CUI-2)
Unterschrift
Item
signature
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
Item Group
procedures
Weiterführende Bildgebung
Item
additional medical imaging
boolean
Additional (Code-1)
C1524062 (UMLS CUI-1)
MTHU013802 (LOINC-1)
Imaging, Medical (Code-2)
C0025086 (UMLS CUI-2)
Mammografie
Item
Mammography
boolean
C0024671 (UMLS CUI-1)
71651007 (SNOMED CT-1)
10026735 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Mammografie
Item
date Mammography
date
C0024671 (UMLS CUI-1)
71651007 (SNOMED CT-1)
10026735 (MedDRA-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Sonografie
Item
Ultrasonography
boolean
Ultrasonography, Mammary (Code-1)
C0080264 (UMLS CUI-1)
47079000 (SNOMED CT-1)
12 (HL7 V3-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Sonografie
Item
date Ultrasonography
date
Ultrasonography, Mammary (Code-1)
C0080264 (UMLS CUI-1)
47079000 (SNOMED CT-1)
12 (HL7 V3-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Sonstige
Item
other medical imaging
boolean
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Imaging, Medical (Code-2)
C0025086 (UMLS CUI-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Sonstige
Item
date other medical imaging
date
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Imaging, Medical (Code-2)
C0025086 (UMLS CUI-2)
Date in time (Code-3)
C0011008 (UMLS CUI-3)
410671006 (SNOMED CT-3)
MTHU021546 (LOINC-3)
Anmeldung TuKo
Item
cancer conference
boolean
Registration (Code-1)
C1514821 (UMLS CUI-1)
Cancer conference (Code-2)
C0805438 (UMLS CUI-2)
TuKo
Item
Date cancer conference
date
Cancer conference:Time Stamp -- Date and Time:Point in time:Cancer.To be specified in another part of the message:Quantitative (Code-1)
C0804663 (UMLS CUI-1)
21875-0 (LOINC-1)
reguläre weitere Vorsorge
Item
Aftercare
boolean
C0001758 (UMLS CUI-1)
413467001 (SNOMED CT-1)
Wiedervorstellung
Item
Follow-Up
boolean
Follow-up visit (procedure) (Code-1)
C0589121 (UMLS CUI-1)
185389009 (SNOMED CT-1)
Wiedervorstellung
Item
Date Follow-Up
date
Follow-up visit (procedure) (Code-1)
C0589121 (UMLS CUI-1)
185389009 (SNOMED CT-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Freitext
Item
free text
string
Free Text Format (Code-1)
C2348713 (UMLS CUI-1)
Datum
Item
Date
date
Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Signature of responsible attending physician on file (Code-2)
C0807938 (UMLS CUI-2)
Unterschrift
Item
signature
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
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