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ID
18112
Beschrijving
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: OP Planung Bereich Senologie
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Versies (1)
- 20-10-16 20-10-16 -
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20 oktober 2016
DOI
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Creative Commons BY-NC 3.0
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Senology surgery planning University Hospital Muenster (UKM)
Senology surgery planning University Hospital Muenster (UKM)
- StudyEvent: ODM
Similar models
Senology surgery planning University Hospital Muenster (UKM)
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
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])
C3854259 (UMLS CUI [1,2])
CL Item
links (1)
CL Item
rechts (2)
CL Item
beidseits (3)
Location
Item
Lage
text
C0450429 (UMLS CUI [1])
CL Item
B3 (1)
CL Item
Benigne (2)
CL Item
DCIS (3)
CL Item
Invasiv (4)
CL Item
andere (1)
CL Item
IL (2)
CL Item
NOS (3)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
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])
C0221198 (UMLS CUI [1,2])
MR-Befund
Item
Befund MR
boolean
C0344104 (UMLS CUI [1,1])
C1285578 (UMLS CUI [1,2])
C1285578 (UMLS CUI [1,2])
Additional lesion
Item
zusätzlicher Herdbefund
boolean
C0221198 (UMLS CUI [1,1])
C1524062 (UMLS CUI [1,2])
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])
C1301886 (UMLS CUI [1,2])
Residual calcification
Item
Restkalk
boolean
C0520594 (UMLS CUI [1,1])
C1609982 (UMLS CUI [1,2])
C1609982 (UMLS CUI [1,2])
Mammography BI-RADS
Item
MG BRRADS
text
C1511314 (UMLS CUI [1,1])
C0024671 (UMLS CUI [1,2])
C0024671 (UMLS CUI [1,2])
Sonography BI-RADS
Item
Sono BRRADS
text
C1511314 (UMLS CUI [1,1])
C0041618 (UMLS CUI [1,2])
C0041618 (UMLS CUI [1,2])
MRT BI-RADS
Item
MRT BRRADS
text
C1511314 (UMLS CUI [1,1])
C0024485 (UMLS CUI [1,2])
C0024485 (UMLS CUI [1,2])
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])
C1301732 (UMLS CUI [1,2])
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])
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])
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])
C0449788 (UMLS CUI [1,2])
Comment markings
Item
Kommentar Markierungen
text
C0473516 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
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])
CL Item
Aphinity (1)
CL Item
GEPAR SIXTO (2)
CL Item
Schmerzstudie (3)
Item
HormonrezeptorStatus: Östrogen
integer
C2919271 (UMLS CUI [1])
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])
CL Item
negativ (N)
CL Item
positiv (P)
Item
HormonrezeptorStatus: Progesteron positiv
integer
C2919590 (UMLS CUI [1])
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])
C0031831 (UMLS CUI [1,2])