ID

16882

Description

Freigabe zur Verarbeitung durch Frau Prof. Rössig, Quellenangabe: "Pädiatrische Hämatologie und Onkologie, UKM" Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster Released for adaption by Frau Prof. Rössig Source: Pediatric Hematology und Oncology, University hospital Münster

Keywords

Versions (1)
  1. 8/12/16 8/12/16 -
Uploaded on

August 12, 2016

DOI

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License

Creative Commons BY-NC 3.0
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UKM-Pediatric Hematology und Oncology Patient Admittance Form

German

Pädiatrischer Hämatologie und Onkologie Aufnahmebogen

1 forms  
Demographie
Description

Demographie

Patienten Name
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Adresse des Patienten
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Versicherter
Description

Health insured person

Data type

text

Alias
UMLS CUI [1,1]
C0376629
UMLS CUI [1,2]
C0680379
Arbeitgeber:
Description

Employer

Data type

text

Alias
UMLS CUI [1]
C1274022
Kostenträger
Description

Health insurance

Data type

text

Alias
UMLS CUI [1]
C0021682
Angehörige
Description

Relatives

Data type

text

Alias
UMLS CUI [1]
C0080103
Einweiser
Description

Referring physician

Data type

text

Alias
UMLS CUI [1]
C1709880
Größe
Description

Height

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Gewicht
Description

Weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Körperoberfläche
Description

Body surface area

Data type

float

Measurement units
  • m²
Alias
UMLS CUI [1]
C0005902
m²
Diagnose
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Stadium
Description

Stage

Data type

text

Alias
UMLS CUI [1]
C0449394
Geplante Aufnahme am
Description

Planned Hospitalization Date

Data type

date

Alias
UMLS CUI [1,1]
C0019993
UMLS CUI [1,2]
C0011008
Protokoll/Arm:
Description

Study protocol

Data type

text

Alias
UMLS CUI [1]
C2348563
Geplanter Block
Description

Treatment course

Data type

text

Alias
UMLS CUI [1]
C0599880
Dosisreduktion
Description

Dose reduction

Data type

boolean

Alias
UMLS CUI [1]
C1707814
Wenn ja, welche Dosisreduktion?
Description

Type of dose reduction

Data type

text

Alias
UMLS CUI [1]
C1707814
Wenn ja, warum wurde die Dosis reduziert?
Description

Reason for dose reduction

Data type

text

Alias
UMLS CUI [1,1]
C1707814
UMLS CUI [1,2]
C0566251
Bestrahlung?
Description

Irradiation

Data type

boolean

Alias
UMLS CUI [1]
C1522449
Bestrahlungsdosis
Description

Irradiation dose

Data type

integer

Measurement units
  • Gy
Alias
UMLS CUI [1]
C2169144
Gy
Bestrahlungsfeld
Description

Irradiation field

Data type

text

Alias
UMLS CUI [1]
C2169147
Besondere Supportivtherapie?
Description

Supportive treatment

Data type

boolean

Alias
UMLS CUI [1]
C0344211
Welche besondere Supportivtherapie?
Description

Type of supportive treatment

Data type

text

Alias
UMLS CUI [1]
C0344211
Warum besondere Supportivtherapie?
Description

Reason for supportive treatment

Data type

text

Alias
UMLS CUI [1,1]
C0344211
UMLS CUI [1,2]
C0566251
Sonstige Modifikation oder Besonderheiten
Description

Treatment modifications

Data type

boolean

Alias
UMLS CUI [1]
C1299575
Welche sonstige Modifikation oder Besonderheiten?
Description

Treatment modifications

Data type

text

Alias
UMLS CUI [1]
C1299575
Klinische Untersuchung
Description

Klinische Untersuchung

Patient/in untersucht?
Description

Physical examination

Data type

boolean

Alias
UMLS CUI [1]
C0031809
Wenn ja, Datum der Untersuchung
Description

Date of examination

Data type

date

Alias
UMLS CUI [1]
C2826643
Wenn nicht untersucht, warum nicht?
Description

Physical examination

Data type

text

Alias
UMLS CUI [1]
C0031809
Infektiösität
Description

Infectious

Data type

boolean

Alias
UMLS CUI [1]
C0009450
Infektiösität: bitte genauer bezeichnen
Description

Infectious

Data type

text

Alias
UMLS CUI [1]
C0009450
Isolierung
Description

Isolation

Data type

boolean

Alias
UMLS CUI [1]
C0205409
Klinische Kontraindikation gegen Chemo?
Description

Contraindication

Data type

boolean

Alias
UMLS CUI [1]
C1301624
Wenn ja, welche Kontraindikation(en)?
Description

Contraindication

Data type

text

Alias
UMLS CUI [1]
C1301624
Allgemeinzustand gut
Description

Health status

Data type

boolean

Alias
UMLS CUI [1]
C0018759
Keine Infektion
Description

Infection

Data type

boolean

Alias
UMLS CUI [1]
C3714514
Keine Antibiose
Description

Antibiotics

Data type

boolean

Alias
UMLS CUI [1]
C0003232
G-CSF >48h her
Description

G-CSF

Data type

boolean

Alias
UMLS CUI [1]
C0079459
Labor und apparative Untersuchungen
Description

Labor und apparative Untersuchungen

Blutbild
Description

Blood count

Data type

integer

Alias
UMLS CUI [1]
C0005771
Grenzwertprotokoll Leukozyten
Description

Normal limits leucocytes

Data type

float

Measurement units
  • /µl
Alias
UMLS CUI [1,1]
C0442816
UMLS CUI [1,2]
C0023516
/µl
Blutbild Leukozyten
Description

Blood count leucocytes

Data type

float

Measurement units
  • /µl
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0023516
/µl
Grenzwertprotokoll Granulozyten
Description

Normal limits granulocytes

Data type

integer

Measurement units
  • %
Alias
UMLS CUI [1,1]
C0442816
UMLS CUI [1,2]
C0018183
%
Blutbild Granulozyten
Description

Blood count granulocytes

Data type

integer

Measurement units
  • %
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0018183
%
Grenzwertprotokoll Thrombozyten
Description

Normal limits platelets

Data type

float

Measurement units
  • /µl
Alias
UMLS CUI [1,1]
C0442816
UMLS CUI [1,2]
C0005821
/µl
Blutbild Thrombozyten
Description

Blood count platelets

Data type

float

Measurement units
  • /µl
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0005821
/µl
Datum Blutbild
Description

Blood count date

Data type

date

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0011008
Elektrolyte
Description

Electrolytes

Data type

integer

Alias
UMLS CUI [1]
C0013832
Elektrolyte:ggf Werte
Description

Electrolytes

Data type

text

Alias
UMLS CUI [1]
C0013832
CRP
Description

CRP

Data type

integer

Alias
UMLS CUI [1]
C0006560
CRP:ggf Werte
Description

CRP

Data type

float

Measurement units
  • md/dl
Alias
UMLS CUI [1]
C0201657
md/dl
Kreatinin
Description

Creatinine

Data type

integer

Alias
UMLS CUI [1]
C0201976
Kreatinin
Description

Creatinine

Data type

float

Measurement units
  • mg/dl
Alias
UMLS CUI [1]
C0201976
mg/dl
Kreatinin clearance nach Schwartz
Description

Creatinine clearance

Data type

integer

Alias
UMLS CUI [1]
C0373595
Kreatinin clearance nach Schwartz
Description

Creatinine clearance

Data type

float

Alias
UMLS CUI [1]
C0373595
Rossl-Check vor IFO
Description

Rossl-Check before IFO

Data type

integer

Alias
UMLS CUI [1,1]
C0020823
UMLS CUI [1,2]
C1827900
Rossl-Check vor IFO
Description

Rossl-Check before IFO

Data type

integer

Alias
UMLS CUI [1,1]
C0020823
UMLS CUI [1,2]
C1827900
Leberwerte
Description

Liver panel

Data type

integer

Alias
UMLS CUI [1]
C0023901
Leberwerte (Bili,Transaminasen):Werte
Description

Liver panel

Data type

text

Alias
UMLS CUI [1]
C0023901
Herzecho (FS)
Description

Cardiac ultrasound (FS)

Data type

integer

Alias
UMLS CUI [1]
C1655737
Herzecho (FS)
Description

Cardiac ultrasound

Data type

integer

Measurement units
  • FS-Wert
Alias
UMLS CUI [1]
C1655737
FS-Wert
Hörtest
Description

Hearing test

Data type

integer

Alias
UMLS CUI [1]
C0018786
Hörtest Befund
Description

Hearing test

Data type

text

Alias
UMLS CUI [1]
C0018786
Sonstige Untersuchungen/Narkosen etc (auch geplant)
Description

Other examinations and procedures

Data type

boolean

Alias
UMLS CUI [1,1]
C0554839
UMLS CUI [1,2]
C1948041
Sonstige Untersuchungen/Narkosen etc (auch geplant):Wenn ja, was und wann
Description

Other examinations and procedures

Data type

text

Alias
UMLS CUI [1,1]
C0554839
UMLS CUI [1,2]
C1948041
Therapieplan
Description

Therapieplan

Therapieplan
Description

Treatment plan

Data type

integer

Alias
UMLS CUI [1]
C0599880
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Similar models

Pädiatrischer Hämatologie und Onkologie Aufnahmebogen

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Demographie
Patient name
Item
Patienten Name
text
C1299487 (UMLS CUI [1])
Patient address
Item
Adresse des Patienten
text
C0421449 (UMLS CUI [1])
Health insured person
Item
Versicherter
text
C0376629 (UMLS CUI [1,1])
C0680379 (UMLS CUI [1,2])
Employer
Item
Arbeitgeber:
text
C1274022 (UMLS CUI [1])
Health insurance
Item
Kostenträger
text
C0021682 (UMLS CUI [1])
Relatives
Item
Angehörige
text
C0080103 (UMLS CUI [1])
Referring physician
Item
Einweiser
text
C1709880 (UMLS CUI [1])
Height
Item
Größe
float
C0005890 (UMLS CUI [1])
Weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Body surface area
Item
Körperoberfläche
float
C0005902 (UMLS CUI [1])
Diagnosis
Item
Diagnose
text
C0011900 (UMLS CUI [1])
Stage
Item
Stadium
text
C0449394 (UMLS CUI [1])
Planned Hospitalization Date
Item
Geplante Aufnahme am
date
C0019993 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Study protocol
Item
Protokoll/Arm:
text
C2348563 (UMLS CUI [1])
Treatment course
Item
Geplanter Block
text
C0599880 (UMLS CUI [1])
Dose reduction
Item
Dosisreduktion
boolean
C1707814 (UMLS CUI [1])
Type of dose reduction
Item
Wenn ja, welche Dosisreduktion?
text
C1707814 (UMLS CUI [1])
Reason for dose reduction
Item
Wenn ja, warum wurde die Dosis reduziert?
text
C1707814 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Irradiation
Item
Bestrahlung?
boolean
C1522449 (UMLS CUI [1])
Irradiation dose
Item
Bestrahlungsdosis
integer
C2169144 (UMLS CUI [1])
Irradiation field
Item
Bestrahlungsfeld
text
C2169147 (UMLS CUI [1])
Supportive treatment
Item
Besondere Supportivtherapie?
boolean
C0344211 (UMLS CUI [1])
Type of supportive treatment
Item
Welche besondere Supportivtherapie?
text
C0344211 (UMLS CUI [1])
Reason for supportive treatment
Item
Warum besondere Supportivtherapie?
text
C0344211 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Treatment modifications
Item
Sonstige Modifikation oder Besonderheiten
boolean
C1299575 (UMLS CUI [1])
Treatment modifications
Item
Welche sonstige Modifikation oder Besonderheiten?
text
C1299575 (UMLS CUI [1])
Item Group
Klinische Untersuchung
Physical examination
Item
Patient/in untersucht?
boolean
C0031809 (UMLS CUI [1])
Date of examination
Item
Wenn ja, Datum der Untersuchung
date
C2826643 (UMLS CUI [1])
Physical examination
Item
Wenn nicht untersucht, warum nicht?
text
C0031809 (UMLS CUI [1])
Infectious
Item
Infektiösität
boolean
C0009450 (UMLS CUI [1])
Infectious
Item
Infektiösität: bitte genauer bezeichnen
text
C0009450 (UMLS CUI [1])
Isolation
Item
Isolierung
boolean
C0205409 (UMLS CUI [1])
Contraindication
Item
Klinische Kontraindikation gegen Chemo?
boolean
C1301624 (UMLS CUI [1])
Contraindication
Item
Wenn ja, welche Kontraindikation(en)?
text
C1301624 (UMLS CUI [1])
Health status
Item
Allgemeinzustand gut
boolean
C0018759 (UMLS CUI [1])
Infection
Item
Keine Infektion
boolean
C3714514 (UMLS CUI [1])
Antibiotics
Item
Keine Antibiose
boolean
C0003232 (UMLS CUI [1])
G-CSF
Item
G-CSF >48h her
boolean
C0079459 (UMLS CUI [1])
Item Group
Labor und apparative Untersuchungen
Item
Blutbild
integer
C0005771 (UMLS CUI [1])
Blood count
Code List
Blutbild
CL Item
Niedrig (1)
CL Item
Genügend (2)
Normal limits leucocytes
Item
Grenzwertprotokoll Leukozyten
float
C0442816 (UMLS CUI [1,1])
C0023516 (UMLS CUI [1,2])
Blood count leucocytes
Item
Blutbild Leukozyten
float
C0005771 (UMLS CUI [1,1])
C0023516 (UMLS CUI [1,2])
Normal limits granulocytes
Item
Grenzwertprotokoll Granulozyten
integer
C0442816 (UMLS CUI [1,1])
C0018183 (UMLS CUI [1,2])
Blood count granulocytes
Item
Blutbild Granulozyten
integer
C0005771 (UMLS CUI [1,1])
C0018183 (UMLS CUI [1,2])
Normal limits platelets
Item
Grenzwertprotokoll Thrombozyten
float
C0442816 (UMLS CUI [1,1])
C0005821 (UMLS CUI [1,2])
Blood count platelets
Item
Blutbild Thrombozyten
float
C0005771 (UMLS CUI [1,1])
C0005821 (UMLS CUI [1,2])
Blood count date
Item
Datum Blutbild
date
C0005771 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Elektrolyte
integer
C0013832 (UMLS CUI [1])
Electrolytes
Code List
Elektrolyte
CL Item
erforderlich, aber nicht durchgeführt (1)
CL Item
pathologisch (2)
CL Item
ohne Befund (3)
Electrolytes
Item
Elektrolyte:ggf Werte
text
C0013832 (UMLS CUI [1])
Item
CRP
integer
C0006560 (UMLS CUI [1])
Electrolytes
Code List
CRP
CL Item
erforderlich, aber nicht durchgeführt (1)
CL Item
pathologisch (2)
CL Item
ohne Befund (3)
CRP
Item
CRP:ggf Werte
float
C0201657 (UMLS CUI [1])
Item
Kreatinin
integer
C0201976 (UMLS CUI [1])
Electrolytes
Code List
Kreatinin
CL Item
nicht erforderlich (1)
CL Item
erforderlich, aber nicht durchgeführt (2)
CL Item
pathologisch (3)
CL Item
ohne Befund (4)
Creatinine
Item
Kreatinin
float
C0201976 (UMLS CUI [1])
Item
Kreatinin clearance nach Schwartz
integer
C0373595 (UMLS CUI [1])
Electrolytes
Code List
Kreatinin clearance nach Schwartz
CL Item
nicht erforderlich (1)
CL Item
erforderlich, aber nicht durchgeführt (2)
CL Item
pathologisch (3)
CL Item
ohne Befund (4)
Creatinine clearance
Item
Kreatinin clearance nach Schwartz
float
C0373595 (UMLS CUI [1])
Item
Rossl-Check vor IFO
integer
C0020823 (UMLS CUI [1,1])
C1827900 (UMLS CUI [1,2])
Electrolytes
Code List
Rossl-Check vor IFO
CL Item
nicht erforderlich (1)
CL Item
erforderlich, aber nicht durchgeführt (2)
CL Item
pathologisch (3)
CL Item
ohne Befund (4)
Rossl-Check before IFO
Item
Rossl-Check vor IFO
integer
C0020823 (UMLS CUI [1,1])
C1827900 (UMLS CUI [1,2])
Item
Leberwerte
integer
C0023901 (UMLS CUI [1])
Electrolytes
Code List
Leberwerte
CL Item
nicht erforderlich (1)
CL Item
erforderlich, aber nicht durchgeführt (2)
CL Item
pathologisch (3)
CL Item
ohne Befund (4)
Liver panel
Item
Leberwerte (Bili,Transaminasen):Werte
text
C0023901 (UMLS CUI [1])
Item
Herzecho (FS)
integer
C1655737 (UMLS CUI [1])
Electrolytes
Code List
Herzecho (FS)
CL Item
nicht erforderlich (1)
CL Item
erforderlich, aber nicht durchgeführt (2)
CL Item
pathologisch (3)
CL Item
ohne Befund (4)
Cardiac ultrasound
Item
Herzecho (FS)
integer
C1655737 (UMLS CUI [1])
Item
Hörtest
integer
C0018786 (UMLS CUI [1])
Electrolytes
Code List
Hörtest
CL Item
nicht erforderlich (1)
CL Item
erforderlich, aber nicht durchgeführt (2)
CL Item
pathologisch (3)
CL Item
ohne Befund (4)
Hearing test
Item
Hörtest Befund
text
C0018786 (UMLS CUI [1])
Other examinations and procedures
Item
Sonstige Untersuchungen/Narkosen etc (auch geplant)
boolean
C0554839 (UMLS CUI [1,1])
C1948041 (UMLS CUI [1,2])
Other examinations and procedures
Item
Sonstige Untersuchungen/Narkosen etc (auch geplant):Wenn ja, was und wann
text
C0554839 (UMLS CUI [1,1])
C1948041 (UMLS CUI [1,2])
Item Group
Therapieplan
Item
Therapieplan
integer
C0599880 (UMLS CUI [1])
Treatment plan
Code List
Therapieplan
CL Item
liegt nicht bei (1)
CL Item
liegt berechnet und unterschrieben bei (2)
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