ID

18112

Description

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: OP Planung Bereich Senologie

Keywords

Versions (1)
  1. 10/20/16 10/20/16 -
Uploaded on

October 20, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Senology surgery planning University Hospital Muenster (UKM)

German

Senology surgery planning University Hospital Muenster (UKM)

1 forms  
Demographische Informationen
Description

Demographische Informationen

Patientenname
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Geburtsdatum
Description

Birth Date

Data type

date

Alias
UMLS CUI [1]
C0421451
Aufnahmedatum und Uhrzeit
Description

Date and time of admission

Data type

datetime

Alias
UMLS CUI [1,1]
C1302393
UMLS CUI [1,2]
C3854259
Befundung des Mammacarcinoms zur OP-Planung
Description

Befundung des Mammacarcinoms zur OP-Planung

Seite
Description

Laterality

Data type

integer

Alias
UMLS CUI [1]
C0925205
Lage
Description

Location

Data type

text

Alias
UMLS CUI [1]
C0450429
Histologie
Description

Histology

Data type

integer

Alias
UMLS CUI [1]
C0019638
Invasiv-Typ
Description

Invasive type

Data type

integer

Alias
UMLS CUI [1,1]
C0853879
UMLS CUI [1,2]
C0332307
Histologisches Grading
Description

Grading

Data type

integer

Alias
UMLS CUI [1]
C0919553
DCIS Kerngrad
Description

DCIS

Data type

integer

Alias
UMLS CUI [1,1]
C0007124
UMLS CUI [1,2]
C0441800
Durchmesser Herd
Description

Diameter of lesion

Data type

integer

Alias
UMLS CUI [1,1]
C1301886
UMLS CUI [1,2]
C0221198
Befund MR
Description

MR-Befund

Data type

boolean

Alias
UMLS CUI [1,1]
C0344104
UMLS CUI [1,2]
C1285578
zusätzlicher Herdbefund
Description

Additional lesion

Data type

boolean

Alias
UMLS CUI [1,1]
C0221198
UMLS CUI [1,2]
C1524062
Durchm AST
Description

Diameter AST

Data type

integer

Measurement units
  • mm
Alias
UMLS CUI [1]
C1301886
mm
Durchm MK (mm)
Description

Diameter micro calcification

Data type

integer

Alias
UMLS CUI [1,1]
C0520594
UMLS CUI [1,2]
C1301886
Restkalk
Description

Residual calcification

Data type

boolean

Alias
UMLS CUI [1,1]
C0520594
UMLS CUI [1,2]
C1609982
MG BRRADS
Description

Mammography BI-RADS

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0024671
Sono BRRADS
Description

Sonography BI-RADS

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0041618
MRT BRRADS
Description

MRT BI-RADS

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0024485
Brustgröße
Description

Breast size

Data type

integer

Alias
UMLS CUI [1]
C0425782
Mastektomie
Description

ME

Data type

boolean

Alias
UMLS CUI [1,1]
C0024881
UMLS CUI [1,2]
C1301732
Rekonstruktion
Description

Breast Reconstruction

Data type

integer

Alias
UMLS CUI [1]
C0085076
Brusterhaltende Therapie
Description

Breast-conserving therapy

Data type

boolean

Alias
UMLS CUI [1]
C0917927
onkopl BET
Description

oncoplastic Breast-conserving therapy

Data type

boolean

Alias
UMLS CUI [1]
C3828706
Excisionsbiopsie
Description

Excision biopsy

Data type

boolean

Alias
UMLS CUI [1]
C0184921
Nachresektion
Description

Revision resection

Data type

boolean

Alias
UMLS CUI [1]
C0558347
Maße Segment (mm)
Description

Anatomical segmentation size

Data type

integer

Alias
UMLS CUI [1,1]
C0441635
UMLS CUI [1,2]
C0456389
Sonografische Markierung
Description

Sonographic marking

Data type

boolean

Alias
UMLS CUI [1]
C2317015
stereotakt Markierung
Description

stereotactic Marking

Data type

boolean

Alias
UMLS CUI [1,1]
C1514967
UMLS CUI [1,2]
C0455084
MRT Markierung
Description

MRI marking

Data type

boolean

Alias
UMLS CUI [1]
C2316343
Anzahl Markierungen
Description

Number of markings

Data type

integer

Alias
UMLS CUI [1,1]
C0473516
UMLS CUI [1,2]
C0449788
Kommentar Markierungen
Description

Comment markings

Data type

text

Alias
UMLS CUI [1,1]
C0473516
UMLS CUI [1,2]
C0947611
Präparate Radiographie
Description

Specimen mammography

Data type

boolean

Alias
UMLS CUI [1]
C0203031
Makro
Description

Sample macroscopy

Data type

boolean

Alias
UMLS CUI [1]
C0430385
Scheiben Radiographie
Description

Pathological specimen X-ray

Data type

boolean

Alias
UMLS CUI [1]
C0412004
Sentinel Lymphknoten Biopsie
Description

SLNB

Data type

boolean

Alias
UMLS CUI [1]
C0796693
ALND
Description

Axillary lymph node dissection

Data type

boolean

Alias
UMLS CUI [1]
C0193867
Intraoperative Strahlentherapie
Description

IORT

Data type

boolean

Alias
UMLS CUI [1]
C0338240
Studien
Description

Clinical trials

Data type

integer

Alias
UMLS CUI [1]
C0008976
HormonrezeptorStatus: Östrogen
Description

Hormone receptor status for estrogen

Data type

integer

Alias
UMLS CUI [1]
C2919271
Hormonrezeptor Status: Östrogen positiv
Description

Hormone receptor status for estrogen

Data type

integer

Measurement units
  • %
Alias
UMLS CUI [1]
C2919271
%
HormonrezeptorStatus: Progesteron
Description

Hormone receptor status for progesterone

Data type

integer

Alias
UMLS CUI [1]
C2919590
HormonrezeptorStatus: Progesteron positiv
Description

Hormone receptor status for progesterone

Data type

integer

Measurement units
  • %
Alias
UMLS CUI [1]
C2919590
Her-2/neu
Description

HER2/neu

Data type

integer

Alias
UMLS CUI [1]
C1512413
Genomische Untersuchung
Description

Genomic exam

Data type

boolean

Alias
UMLS CUI [1]
C2349866
Besondheiten
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Verantwortlicher Arzt
Description

Responsible physician

Data type

text

Alias
UMLS CUI [1,1]
C1273518
UMLS CUI [1,2]
C0031831
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Similar models

Senology surgery planning University Hospital Muenster (UKM)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Demographische Informationen
Patient Name
Item
Patientenname
text
C1299487 (UMLS CUI [1])
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Date and time of admission
Item
Aufnahmedatum und Uhrzeit
datetime
C1302393 (UMLS CUI [1,1])
C3854259 (UMLS CUI [1,2])
Item Group
Befundung des Mammacarcinoms zur OP-Planung
Item
Seite
integer
C0925205 (UMLS CUI [1])
Laterality
Code List
Seite
CL Item
links (1)
CL Item
rechts (2)
CL Item
beidseits (3)
Location
Item
Lage
text
C0450429 (UMLS CUI [1])
Item
Histologie
integer
C0019638 (UMLS CUI [1])
Histology
Code List
Histologie
CL Item
B3 (1)
CL Item
Benigne (2)
CL Item
DCIS (3)
CL Item
Invasiv (4)
Item
Invasiv-Typ
integer
C0853879 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Invasive type
Code List
Invasiv-Typ
CL Item
andere (1)
CL Item
IL (2)
CL Item
NOS (3)
Item
Histologisches Grading
integer
C0919553 (UMLS CUI [1])
Grading
Code List
Histologisches Grading
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
Item
DCIS Kerngrad
integer
C0007124 (UMLS CUI [1,1])
C0441800 (UMLS CUI [1,2])
Grading
Code List
DCIS Kerngrad
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
Diameter of lesion
Item
Durchmesser Herd
integer
C1301886 (UMLS CUI [1,1])
C0221198 (UMLS CUI [1,2])
MR-Befund
Item
Befund MR
boolean
C0344104 (UMLS CUI [1,1])
C1285578 (UMLS CUI [1,2])
Additional lesion
Item
zusätzlicher Herdbefund
boolean
C0221198 (UMLS CUI [1,1])
C1524062 (UMLS CUI [1,2])
Diameter AST
Item
Durchm AST
integer
C1301886 (UMLS CUI [1])
Diameter micro calcification
Item
Durchm MK (mm)
integer
C0520594 (UMLS CUI [1,1])
C1301886 (UMLS CUI [1,2])
Residual calcification
Item
Restkalk
boolean
C0520594 (UMLS CUI [1,1])
C1609982 (UMLS CUI [1,2])
Mammography BI-RADS
Item
MG BRRADS
text
C1511314 (UMLS CUI [1,1])
C0024671 (UMLS CUI [1,2])
Sonography BI-RADS
Item
Sono BRRADS
text
C1511314 (UMLS CUI [1,1])
C0041618 (UMLS CUI [1,2])
MRT BI-RADS
Item
MRT BRRADS
text
C1511314 (UMLS CUI [1,1])
C0024485 (UMLS CUI [1,2])
Item
Brustgröße
integer
C0425782 (UMLS CUI [1])
Breast size
Code List
Brustgröße
CL Item
A (1)
CL Item
B (2)
CL Item
C (3)
CL Item
D (4)
CL Item
2D (5)
ME
Item
Mastektomie
boolean
C0024881 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
Item
Rekonstruktion
integer
C0085076 (UMLS CUI [1])
Breast Reconstruction
Code List
Rekonstruktion
CL Item
mit (1)
CL Item
ohne (2)
Breast-conserving therapy
Item
Brusterhaltende Therapie
boolean
C0917927 (UMLS CUI [1])
oncoplastic Breast-conserving therapy
Item
onkopl BET
boolean
C3828706 (UMLS CUI [1])
Excision biopsy
Item
Excisionsbiopsie
boolean
C0184921 (UMLS CUI [1])
Revision resection
Item
Nachresektion
boolean
C0558347 (UMLS CUI [1])
Anatomical segmentation size
Item
Maße Segment (mm)
integer
C0441635 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
Sonographic marking
Item
Sonografische Markierung
boolean
C2317015 (UMLS CUI [1])
stereotactic Marking
Item
stereotakt Markierung
boolean
C1514967 (UMLS CUI [1,1])
C0455084 (UMLS CUI [1,2])
MRI marking
Item
MRT Markierung
boolean
C2316343 (UMLS CUI [1])
Number of markings
Item
Anzahl Markierungen
integer
C0473516 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Comment markings
Item
Kommentar Markierungen
text
C0473516 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Specimen mammography
Item
Präparate Radiographie
boolean
C0203031 (UMLS CUI [1])
Sample macroscopy
Item
Makro
boolean
C0430385 (UMLS CUI [1])
Pathological specimen X-ray
Item
Scheiben Radiographie
boolean
C0412004 (UMLS CUI [1])
SLNB
Item
Sentinel Lymphknoten Biopsie
boolean
C0796693 (UMLS CUI [1])
Axillary lymph node dissection
Item
ALND
boolean
C0193867 (UMLS CUI [1])
IORT
Item
Intraoperative Strahlentherapie
boolean
C0338240 (UMLS CUI [1])
Item
Studien
integer
C0008976 (UMLS CUI [1])
Clinical trials
Code List
Studien
CL Item
Aphinity (1)
CL Item
GEPAR SIXTO (2)
CL Item
Schmerzstudie (3)
Item
HormonrezeptorStatus: Östrogen
integer
C2919271 (UMLS CUI [1])
Hormone receptor status for estrogen
Code List
HormonrezeptorStatus: Östrogen
CL Item
negativ (N)
CL Item
positiv (P)
Hormone receptor status for estrogen
Item
Hormonrezeptor Status: Östrogen positiv
integer
C2919271 (UMLS CUI [1])
Item
HormonrezeptorStatus: Progesteron
integer
C2919590 (UMLS CUI [1])
Hormone receptor status for progesterone
Code List
HormonrezeptorStatus: Progesteron
CL Item
negativ (N)
CL Item
positiv (P)
Item
HormonrezeptorStatus: Progesteron positiv
integer
C2919590 (UMLS CUI [1])
Hormone receptor status for progesterone
Code List
HormonrezeptorStatus: Progesteron positiv
Item
Her-2/neu
integer
C1512413 (UMLS CUI [1])
HER2/neu
Code List
Her-2/neu
CL Item
negativ (N)
CL Item
positiv (P)
CL Item
nicht durchgeführt (ND)
Genomic exam
Item
Genomische Untersuchung
boolean
C2349866 (UMLS CUI [1])
Comments
Item
Besondheiten
text
C0947611 (UMLS CUI [1])
Responsible physician
Item
Verantwortlicher Arzt
text
C1273518 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
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