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ID
17468
Description
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Anamnese Brustsprechstunde MS.
Keywords
Versions (2)
- 9/16/16 9/16/16 -
- 9/20/21 9/20/21 -
Uploaded on
September 16, 2016
DOI
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License
Creative Commons BY-NC 3.0
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Anamnesis Breast Consultation University Hospital Muenster (UKM)
Anamnesis Breast Consultation University Hospital Muenster (UKM)
- StudyEvent: ODM
Similar models
Anamnesis Breast Consultation University Hospital Muenster (UKM)
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Anamnese Brustsprechstunde
C0006141 (UMLS CUI-1)
C0025084 (UMLS CUI-2)
C0025084 (UMLS CUI-2)
anamnesis date
Item
Anamnese-Datum:
date
C0025084 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
anamnesis person
Item
Anamnese erhoben durch:
text
C0025084 (UMLS CUI [1,1])
C0010995 (UMLS CUI [1,2])
C0027361 (UMLS CUI [1,3])
C0010995 (UMLS CUI [1,2])
C0027361 (UMLS CUI [1,3])
physician referral letter
Item
Zuweisender Arzt:
text
C2584922 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
C0031831 (UMLS CUI [1,2])
reason for referral
Item
Überweisungsgrund:
text
C0034927 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,2])
Item
Grund des Arztbesuches:
text
C0009818 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,2])
CL Item
Vorsorge (Vorsorge)
CL Item
Nachsorge (Nachsorge)
CL Item
Selbstuntersuchung (Selbstuntersuchung)
CL Item
Zufallsbefund (Zufallsbefund)
CL Item
Symptomatik (Symptomatik)
CL Item
Screening (Screening)
body weight
Item
Gewicht:
float
C0005910 (UMLS CUI [1])
body height
Item
Größe:
float
C0005890 (UMLS CUI [1])
CL Item
prämenopause (prämenopause)
CL Item
postmenopause (postmenopause)
CL Item
perimenopausal (perimenopausal)
CL Item
unbekannt (unbekannt)
pregnancies
Item
Schwangerschaften:
integer
C0032961 (UMLS CUI [1])
lactation
Item
Stillzeit (Monaten):
integer
C0006147 (UMLS CUI [1,1])
C0439231 (UMLS CUI [1,2])
C0439231 (UMLS CUI [1,2])
allergies
Item
Allergien
text
C0020517 (UMLS CUI [1])
CL Item
Nikotin (Nikotin)
CL Item
Alkohol (Alkohol)
cigarettes per day
Item
Anz. Zigaretten/Tag
integer
C3694146 (UMLS CUI [1])
thrombosis
Item
Thrombose:
boolean
C0040053 (UMLS CUI [1])
medication
Item
Medikament
text
C0013227 (UMLS CUI [1])
condition or surgery
Item
Erkrankungen/Operationen
text
C0521987 (UMLS CUI [1])
C0009488 (UMLS CUI [2])
C0009488 (UMLS CUI [2])
condition date
Item
Datum/Jahr
date
C0521987 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
therapy
Item
Therapie
text
C0087111 (UMLS CUI [1])
mammography
Item
Mommographie
boolean
C0024671 (UMLS CUI [1])
mammography date
Item
Mammographie am
date
C0024671 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
sonography
Item
Sonographie
boolean
C0080264 (UMLS CUI [1])
sonography date
Item
Sonographie am
date
C0080264 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
MR-MG
Item
MR-MG
boolean
C0344104 (UMLS CUI [1])
MR-MG date
Item
MR-MG am
date
C0344104 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Item
MR-BIRADS Rechts
text
C0917874 (UMLS CUI [1,1])
C1511314 (UMLS CUI [1,2])
C0205090 (UMLS CUI [1,3])
C1511314 (UMLS CUI [1,2])
C0205090 (UMLS CUI [1,3])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
Item
MR-BIRADS Links
text
C0917874 (UMLS CUI [1,1])
C1511314 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,3])
C1511314 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,3])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
histology
Item
Histologie
boolean
C0019638 (UMLS CUI [1])
other external findings
Item
Sonstiges
boolean
CL Item
A (A)
CL Item
B (B)
CL Item
C (C)
CL Item
D (D)
CL Item
>D (>D)
CL Item
keine (keine)
CL Item
mittel (mittel)
CL Item
ausgeprägt (ausgeprägt)
CL Item
ja (ja)
CL Item
li > re (li > re)
CL Item
nein (nein)
CL Item
li < re (li < re)
CL Item
blutig (blutig)
CL Item
ja (ja)
CL Item
milchig (milchig)
CL Item
nein (nein)
CL Item
serös (serös)
CL Item
unauffällig (unauffällig)
CL Item
Einziehung (Einziehung)
CL Item
Plateau (Plateau)
CL Item
Ödem (Ödem)
CL Item
Ulzeration (Ulzeration)
intradermal nodes
Item
Intradermale Knoten:
boolean
C0024103 (UMLS CUI [1,1])
C0150647 (UMLS CUI [1,2])
C0150647 (UMLS CUI [1,2])
inflammatory
Item
Inflammatorisch:
boolean
C0333348 (UMLS CUI [1])
CL Item
weich, gut beurteilbar (weich, gut beurteilbar)
CL Item
knotig, schwer beurteilbar (knotig, schwer beurteilbar)
Item
Auffälliger Tastbef. rechts
text
C2032936 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0750493 (UMLS CUI [1,2])
CL Item
nein (nonpalpabel) (nein (nonpalpabel))
CL Item
solitär (solitär)
CL Item
multiple (multiple)
palpation finding right number
Item
Anzahl:
integer
C2032936 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
C0750493 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
Item
Auffälliger Tastbef. links
text
C2032933 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0750493 (UMLS CUI [1,2])
CL Item
nein (nonpalpabel) (nein (nonpalpabel))
CL Item
solitär (solitär)
CL Item
multiple (multiple)
Item
Anzahl
integer
C2032933 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
C0750493 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
lymphnodes right
Item
Lymphknoten rechts:
text
C0024204 (UMLS CUI [1,1])
C0222600 (UMLS CUI [1,2])
C0222600 (UMLS CUI [1,2])
lymphnodes left
Item
Lymphknoten links:
text
C0024204 (UMLS CUI [1,1])
C0222601 (UMLS CUI [1,2])
C0222601 (UMLS CUI [1,2])
comment
Item
Kommentar
text
C0947611 (UMLS CUI [1])
clock
Item
Uhr
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
C0205210 (UMLS CUI [1,2])
size
Item
Größe (cm)
integer
C1290912 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
C0456389 (UMLS CUI [1,2])
suspicious finding
Item
Suspekt
boolean
C1290912 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0750493 (UMLS CUI [1,2])
clock
Item
Uhr
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
C0205210 (UMLS CUI [1,2])
size
Item
Größe (cm)
integer
C1290912 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
C0456389 (UMLS CUI [1,2])
suspicious finding
Item
Suspekt
boolean
C1290912 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0750493 (UMLS CUI [1,2])
Item Group
Mammasonographie Rechts
C0080264 (UMLS CUI-1)
C0205090 (UMLS CUI-2)
C0205090 (UMLS CUI-2)
number
Item
Nr
integer
C0237753 (UMLS CUI [1])
clock position
Item
Uhr
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
C0205210 (UMLS CUI [1,2])
metric
Item
Metrik
text
C0449453 (UMLS CUI [1,1])
C0080264 (UMLS CUI [1,2])
C0080264 (UMLS CUI [1,2])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
lymphnodes right
Item
Lymphknoten (rechts)
text
C0024204 (UMLS CUI [1,1])
C0222600 (UMLS CUI [1,2])
C0222600 (UMLS CUI [1,2])
Item Group
Mammasonographie Links
C0080264 (UMLS CUI-1)
C0205091 (UMLS CUI-2)
C0205091 (UMLS CUI-2)
number
Item
Nr
integer
C0237753 (UMLS CUI [1])
clock position
Item
Uhr
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
C0205210 (UMLS CUI [1,2])
metric
Item
Metrik
text
C0449453 (UMLS CUI [1,1])
C0080264 (UMLS CUI [1,2])
C0080264 (UMLS CUI [1,2])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
V (V)
lymphnodes left
Item
Lymphknoten (links)
text
C0024204 (UMLS CUI [1,1])
C0222601 (UMLS CUI [1,2])
C0222601 (UMLS CUI [1,2])
biospy performed
Item
Biopsie/Punktion durchgeführt
text
C0005558 (UMLS CUI [1])
punch biopsy
Item
Ultraschallgestützte Stanzbiopsie
boolean
C0184924 (UMLS CUI [1,1])
C0041618 (UMLS CUI [1,2])
C0041618 (UMLS CUI [1,2])
puncture of cyst
Item
Cystenpunktion
boolean
C2733030 (UMLS CUI [1])
lesion
Item
Herdbefund
text
C0221198 (UMLS CUI [1])
number of punches
Item
Anzahl Stanzen
integer
C0182557 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,2])
CL Item
nein (nein )
CL Item
kleiner (kleiner)
CL Item
weg (weg)
documented by photo
Item
Fotodokumentation durchgeführt:
boolean
C0946283 (UMLS CUI [1])
date
Item
Datum:
date
C0011008 (UMLS CUI [1])
signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
additional imaging
Item
Weiterführende Bildgebung
boolean
C1524062 (UMLS CUI [1,1])
C0025086 (UMLS CUI [1,2])
C0025086 (UMLS CUI [1,2])
mammography
Item
Mammographie
boolean
C0024671 (UMLS CUI [1])
mammography date
Item
Mammographie, am
date
C0024671 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
sonography
Item
Sonographie
boolean
C0041618 (UMLS CUI [1])
sonography date
Item
Sonographie, am
date
C0041618 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
other imaging
Item
Sonstiges
boolean
C1533147 (UMLS CUI [1])
other imaging date
Item
Sonstiges, am
date
C1533147 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
registration
Item
Anmeldung
boolean
C1514821 (UMLS CUI [1])
registration MDT
Item
MDT
boolean
registration MDT date
Item
MDT, am
date
registration tumor conference
Item
Tuko
boolean
registration tumor conference date
Item
Tuko, am
date
regular prevention
Item
reguläre weitere Vorsorge
boolean
C2700409 (UMLS CUI [1])
follow-up visit
Item
Wiedervorstellung
boolean
C0589121 (UMLS CUI [1])
follow-up visits date
Item
Wiedervorstellung, am
date
C0589121 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
date
Item
Datum
date
C0011008 (UMLS CUI [1])
signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])