ID

15833

Description

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

Keywords

Versions (1)
  1. 6/15/16 6/15/16 - Julian Varghese
Uploaded on

June 15, 2016

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Creative Commons BY-NC 3.0 Legacy
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surgery treatment - tumortherapy

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
Admininstrative Daten
Description

Admininstrative Daten

Patient surname
Description

Name

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 title
Description

Titel

Data type

string

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

früherer Name

Data type

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
Description

Geburtsdatum

Data type

date

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

Alter

Data type

integer

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

Nationalität

Data type

string

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

Adresse

Data type

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
Description

PLZ

Data type

integer

Alias
UMLS CUI-1
C0421454
SNOMED CT-1
184102003
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
City of residence
Description

Stadt

Data type

string

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

Fallnummer

Data type

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
Description

OP-Bogen

Cancer Diagnosis
Description

Tumordiagnose (ICD-10)

Data type

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
Description

Diagnose-Datum

Data type

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
Description

Datum

Data type

date

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

Wird die Therapie nach Leitlinien durchgeführt

Data type

boolean

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

Grund

Data type

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
Description

ASA

Data type

integer

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

Operative Surgical Procedure

Surgical and medical procedures
Description

OPS-2010

Data type

string

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

Seite

Data type

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
Description

Ziel

Data type

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
Description

welche

Data type

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
Description

Nerverhalt

Data type

boolean

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

falls ja, wo?

Data type

integer

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

Name des Operateurs

Data type

string

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

Lehrassistenz

Data type

string

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

Weitere OP

Data type

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
Description

OPS-2010 (weitere OP)

Data type

string

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

Seite

Data type

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
Description

Ziel

Data type

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
Description

intraoperative Komplikationen

Data type

boolean

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

falls ja, welche

Data type

string

Alias
UMLS CUI-1
C0021890
MedDRA-1
10052620
Code-2
Free Text Format
UMLS CUI-2
C2348713
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Similar models

HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
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)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
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
integer
Finding of American Society of Anesthesiologists physical status classification (finding) (Code-1)
413347006 (SNOMED CT-1)
C1531480 (UMLS CUI [1])
ASA
Code List
ASA
CL Item
A normal healthy patient (1)
CL Item
A patient with mild systemic disease (2)
CL Item
A patient with severe systemic disease (3)
CL Item
A patient with severe systemic disease that is a constant threat to life (4)
CL Item
A moribund patient who is not expected to survive without the operation (5)
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)
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