ID

17411

Description

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: MS Haut Histologie.

Keywords

Versions (1)
  1. 9/12/16 9/12/16 -
Uploaded on

September 12, 2016

DOI

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License

Creative Commons BY-NC 3.0
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MS Skin Histology University Hospital Muenster (UKM)

German

MS Skin Histology University Hospital Muenster (UKM)

1 forms  
Administrative Daten
Description

Administrative Daten

Pat.:
Description

patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Fall-Nr.:
Description

case number

Data type

text

Alias
UMLS CUI [1,1]
C0872057
UMLS CUI [1,2]
C1300638
Geb.Dat.:
Description

birth date

Data type

date

Alias
UMLS CUI [1]
C0421451
Geschlecht
Description

sex

Data type

text

Alias
UMLS CUI [1]
C0150831
Pat.-ID:
Description

patient identifier

Data type

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0030705
PID:
Description

PID

Data type

text

Aufnahmezeit
Description

time of admission

Data type

time

Alias
UMLS CUI [1]
C3854259
Beruf:
Description

occupation

Data type

text

Alias
UMLS CUI [1]
C0421456
Arbeitsg.:
Description

field of work

Data type

text

Alias
UMLS CUI [1,1]
C1521738
UMLS CUI [1,2]
C0028811
Befundet am:
Description

date finding

Data type

date

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C1868671
UMLS CUI [1,3]
C0011008
Histologie
Description

Histologie

Alias
UMLS CUI-1
C1868671
Histologie-Nr.:
Description

histology ID

Data type

text

Alias
UMLS CUI [1,1]
C0019638
UMLS CUI [1,2]
C0600091
Eingangsdatum:
Description

receipt date

Data type

date

Alias
UMLS CUI [1]
C2985846
Station/Amb.:
Description

clinic

Data type

text

Alias
UMLS CUI [1]
C0442592
auswärtig:
Description

external clinic

Data type

text

Operateur
Description

surgeon

Data type

text

Alias
UMLS CUI [1]
C0582175
Stelle der Exzision:
Description

exercision

Data type

text

Alias
UMLS CUI [1,1]
C0728940
UMLS CUI [1,2]
C0475264
Frühere Histologien:
Description

earlier histologies

Data type

text

Alias
UMLS CUI [1,1]
C1868671
UMLS CUI [1,2]
C1279919
Exzisions-Technik:
Description

excision technique

Data type

text

Alias
UMLS CUI [1,1]
C0015252
UMLS CUI [1,2]
C1868671
Anästhesie:
Description

anaesthesia

Data type

text

Alias
UMLS CUI [1]
C0002903
Präparat geteilt:
Description

sample divided

Data type

text

Alias
UMLS CUI [1,1]
C0444099
UMLS CUI [1,2]
C2919031
Gewünschter Biopsat-Anschnitt:
Description

biopsy section

Data type

text

Alias
UMLS CUI [1]
C0449340
Sonstiges:
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
Diagnose/Fragestellung
Description

diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
UMLS CUI [2]
C2315323
Histologie Ergebnisse
Description

Histologie Ergebnisse

Makroskopisch:
Description

macroscopic findings

Data type

text

Alias
UMLS CUI [1,1]
C1551402
UMLS CUI [1,2]
C1868671
Mikroskopisch:
Description

microscopic findings

Data type

text

Alias
UMLS CUI [1,1]
C0369671
UMLS CUI [1,2]
C1868671
Immunhistologie:
Description

immunohistology

Data type

boolean

Alias
UMLS CUI [1]
C0021044
Stanzkartei:
Description

punch biopsy

Data type

text

Alias
UMLS CUI [1]
C0191321
Kritischer Bericht:
Description

critical report

Data type

text

Alias
UMLS CUI [1,1]
C0684224
UMLS CUI [1,2]
C1511545
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Similar models

MS Skin Histology University Hospital Muenster (UKM)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Daten
patient name
Item
Pat.:
text
C1299487 (UMLS CUI [1])
case number
Item
Fall-Nr.:
text
C0872057 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
birth date
Item
Geb.Dat.:
date
C0421451 (UMLS CUI [1])
Item
Geschlecht
text
C0150831 (UMLS CUI [1])
sex
Code List
Geschlecht
CL Item
W (W)
CL Item
M (M)
patient identifier
Item
Pat.-ID:
text
C0600091 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
PID
Item
PID:
text
time of admission
Item
Aufnahmezeit
time
C3854259 (UMLS CUI [1])
occupation
Item
Beruf:
text
C0421456 (UMLS CUI [1])
field of work
Item
Arbeitsg.:
text
C1521738 (UMLS CUI [1,1])
C0028811 (UMLS CUI [1,2])
date finding
Item
Befundet am:
date
C0243095 (UMLS CUI [1,1])
C1868671 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item Group
Histologie
C1868671 (UMLS CUI-1)
histology ID
Item
Histologie-Nr.:
text
C0019638 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
receipt date
Item
Eingangsdatum:
date
C2985846 (UMLS CUI [1])
Item
Station/Amb.:
text
C0442592 (UMLS CUI [1])
clinic
Code List
Station/Amb.:
CL Item
HAUT 2 - Station HAUT 2 (HAUT 2 - Station HAUT 2)
CL Item
HAUT 3 - Station HAUT 3 (HAUT 3 - Station HAUT 3)
CL Item
HAUT 4 - Station HAUT 4 (HAUT 4 - Station HAUT 4)
CL Item
HAUT 5 - Station HAUT 5 (HAUT 5 - Station HAUT 5)
CL Item
HAUT 6 - Station HAUT 6 (HAUT 6 - Station HAUT 6)
CL Item
HAUT AESTH - Hautklinik Ästhetische Dermatologie (HAUT AESTH - Hautklinik Ästhetische Dermatologie)
CL Item
HAUT AI - Hautklinik Autoimmundermatosen (HAUT AI - Hautklinik Autoimmundermatosen)
CL Item
HAUT ALLG - Hautklinik Allergologie (HAUT ALLG - Hautklinik Allergologie)
CL Item
HAUT ANDR - Hautklinik Andrologie-Ambulanz (HAUT ANDR - Hautklinik Andrologie-Ambulanz)
CL Item
HAUT EMBR - Hautklinik eign. Material Allergologie (HAUT EMBR - Hautklinik eign. Material Allergologie)
CL Item
HAUT FOTO - Hautklinik Phototherapie (HAUT FOTO - Hautklinik Phototherapie)
CL Item
HAUT HIST - Hautklinik Histologie (HAUT HIST - Hautklinik Histologie)
CL Item
HAUT IMM - Hautklinik Immunmorphologie (HAUT IMM - Hautklinik Immunmorphologie)
CL Item
HAUT KONSIL - Hautklinik Konsile (HAUT KONSIL - Hautklinik Konsile)
CL Item
HAUT MELANOM - Melanom-Ambulanz (HAUT MELANOM - Melanom-Ambulanz)
CL Item
HAUT ONKO - Hauttumorsprechstunde (HAUT ONKO - Hauttumorsprechstunde)
CL Item
HAUT OPS - Hautklinik Operative Abteilung (HAUT OPS - Hautklinik Operative Abteilung)
CL Item
HAUT PHLE - Hautklinik Phlebologie (HAUT PHLE - Hautklinik Phlebologie)
CL Item
HAUT POLI - Hautklinik Poliklinik (HAUT POLI - Hautklinik Poliklinik)
CL Item
HAUT PRUR - Hautklinik Ambulanz Pruritus Sprechstunde (HAUT PRUR - Hautklinik Ambulanz Pruritus Sprechstunde)
CL Item
HAUT PRV AMB - Hautklinik Privatambulanz (HAUT PRV AMB - Hautklinik Privatambulanz)
CL Item
HAUT PSO - Hautklinik Psoriasis, Genoderamtose (HAUT PSO - Hautklinik Psoriasis, Genoderamtose)
CL Item
HAUT TAGE - TK HAUT (HAUT TAGE - TK HAUT)
CL Item
HAUT WUND - Hautklinik Wundambulanz + Phlebologie (HAUT WUND - Hautklinik Wundambulanz + Phlebologie)
external clinic
Item
auswärtig:
text
surgeon
Item
Operateur
text
C0582175 (UMLS CUI [1])
exercision
Item
Stelle der Exzision:
text
C0728940 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
earlier histologies
Item
Frühere Histologien:
text
C1868671 (UMLS CUI [1,1])
C1279919 (UMLS CUI [1,2])
Item
Exzisions-Technik:
text
C0015252 (UMLS CUI [1,1])
C1868671 (UMLS CUI [1,2])
excision technique
Code List
Exzisions-Technik:
CL Item
Stanze (Stanze)
CL Item
Teilexzision (Teilexzision)
CL Item
Totalexzision (Totalexzision)
CL Item
Shave (Shave)
Item
Anästhesie:
text
C0002903 (UMLS CUI [1])
anaesthesia
Code List
Anästhesie:
CL Item
Lokalanästhesie (Lokalanästhesie)
CL Item
Leitungsanästhesie (Leitungsanästhesie)
CL Item
Narkose (Narkose)
Item
Präparat geteilt:
text
C0444099 (UMLS CUI [1,1])
C2919031 (UMLS CUI [1,2])
sample divided
Code List
Präparat geteilt:
CL Item
Gefriermaterial (Gefriermaterial)
CL Item
Mikrobiologie (Mikrobiologie)
CL Item
Elektronenmikroskopie (Elektronenmikroskopie)
Item
Gewünschter Biopsat-Anschnitt:
text
C0449340 (UMLS CUI [1])
biopsy section
Code List
Gewünschter Biopsat-Anschnitt:
CL Item
quer (quer)
CL Item
längs (längs)
other
Item
Sonstiges:
text
C0205394 (UMLS CUI [1])
diagnosis
Item
Diagnose/Fragestellung
text
C0011900 (UMLS CUI [1])
C2315323 (UMLS CUI [2])
Item Group
Histologie Ergebnisse
macroscopic findings
Item
Makroskopisch:
text
C1551402 (UMLS CUI [1,1])
C1868671 (UMLS CUI [1,2])
microscopic findings
Item
Mikroskopisch:
text
C0369671 (UMLS CUI [1,1])
C1868671 (UMLS CUI [1,2])
immunohistology
Item
Immunhistologie:
boolean
C0021044 (UMLS CUI [1])
punch biopsy
Item
Stanzkartei:
text
C0191321 (UMLS CUI [1])
critical report
Item
Kritischer Bericht:
text
C0684224 (UMLS CUI [1,1])
C1511545 (UMLS CUI [1,2])
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