ID

21755

Description

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: Befund_Brust

Keywords

Versions (2)
  1. 4/19/17 4/19/17 -
  2. 4/28/17 4/28/17 -
Uploaded on

April 28, 2017

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License

Creative Commons BY-NC 3.0
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Breast Finding, University Hospital Cologne

German

Breast Finding, University Hospital Cologne

1 forms  
UFK Brustzentrum, Auftragsdaten
Description

UFK Brustzentrum, Auftragsdaten

Alias
UMLS CUI-1
C0199850
UMLS CUI-2
C1705175
Patient
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Geburtsdatum
Description

Birth Date

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1]
C0421451
dd.mm.yyyy
Geschlecht
Description

Gender

Data type

integer

Alias
UMLS CUI [1]
C0079399
Fall-Nr.
Description

Case ID

Data type

integer

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C1300638
Krankenkasse
Description

Health Insurance

Data type

text

Alias
UMLS CUI [1]
C0021682
PID
Description

Patient ID

Data type

integer

Alias
UMLS CUI [1,1]
C0030705
UMLS CUI [1,2]
C1300638
Auftragsstatus
Description

Order status

Data type

text

Alias
UMLS CUI [1,1]
C1550341
UMLS CUI [1,2]
C0199850
Auftragsnummer
Description

Order identification number

Data type

integer

Alias
UMLS CUI [1,1]
C1300638
UMLS CUI [1,2]
C1705175
UMLS CUI [1,3]
C0199850
Dringlichkeit
Description

Urgency

Data type

text

Alias
UMLS CUI [1,1]
C4049774
UMLS CUI [1,2]
C0199850
Zielbenutzer
Description

Recipient

Data type

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1706077
UMLS CUI [1,3]
C0199850
Leistungsanforderer
Description

Department requesting examination

Data type

text

Alias
UMLS CUI [1,1]
C1705175
UMLS CUI [1,2]
C2986180
UMLS CUI [1,3]
C0019961
Leistungserbringer
Description

Department performing examination

Data type

text

Alias
UMLS CUI [1,1]
C0199850
UMLS CUI [1,2]
C2986180
UMLS CUI [1,3]
C0019961
Angeforderte Leistung
Description

Requested examination

Data type

text

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C0332307
Termin der Untersuchung
Description

Date of examination

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0199850
dd.mm.yyyy
UFK Brustzentrum, Befund Mammasonografie
Description

UFK Brustzentrum, Befund Mammasonografie

Alias
UMLS CUI-1
C0425770
UMLS CUI-2
C0080264
Beurteilbarkeit rechts
Description

Assessability of right breast

Data type

integer

Alias
UMLS CUI [1,1]
C0332306
UMLS CUI [1,2]
C0425770
UMLS CUI [1,3]
C0222600
Beurteilbarkeit links
Description

Assessability of left breast

Data type

integer

Alias
UMLS CUI [1,1]
C0332306
UMLS CUI [1,2]
C0425770
UMLS CUI [1,3]
C0222601
Parenchymdichte rechts
Description

Breast density in right breast

Data type

integer

Alias
UMLS CUI [1,1]
C1659543
UMLS CUI [1,2]
C0222600
Parenchymdichte links
Description

Breast density in left breast

Data type

integer

Alias
UMLS CUI [1,1]
C1659543
UMLS CUI [1,2]
C0222601
Lymphabflussgebiet rechts
Description

Lymphatic drainage right breast

Data type

integer

Alias
UMLS CUI [1,1]
C0398480
UMLS CUI [1,2]
C0222600
Lymphabflussgebiet links
Description

Lymphatic drainage left breast

Data type

integer

Alias
UMLS CUI [1,1]
C0398480
UMLS CUI [1,2]
C0222601
Herdbefund
Description

Lesion

Data type

boolean

Alias
UMLS CUI [1,1]
C0221198
UMLS CUI [1,2]
C0425770
Sonografische Diagnose
Description

Ultrasonographic diagnosis

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0080264
BIRADS Klassifikation
Description

BIRADS Klassifikation

Alias
UMLS CUI-1
C1511314
UMLS CUI-2
C0008902
BI-RADS
Description

BI-RADS

Data type

integer

Alias
UMLS CUI [1]
C1511314
Befund
Description

Breast finding

Data type

text

Alias
UMLS CUI [1]
C0425770
Beurteilung
Description

Evaluation breast finding

Data type

text

Alias
UMLS CUI [1,1]
C0220825
UMLS CUI [1,2]
C0425770
Empfehlung
Description

Recommendation

Data type

text

Alias
UMLS CUI [1,1]
C0034866
UMLS CUI [1,2]
C0425770
Befundet am
Description

Date of finding

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0425770
dd.mm.yyyy
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Similar models

Breast Finding, University Hospital Cologne

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
UFK Brustzentrum, Auftragsdaten
C0199850 (UMLS CUI-1)
C1705175 (UMLS CUI-2)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Item
Geschlecht
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Geschlecht
CL Item
männlich (1)
CL Item
weiblich (2)
Case ID
Item
Fall-Nr.
integer
C1698493 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Health Insurance
Item
Krankenkasse
text
C0021682 (UMLS CUI [1])
Patient ID
Item
PID
integer
C0030705 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Order status
Item
Auftragsstatus
text
C1550341 (UMLS CUI [1,1])
C0199850 (UMLS CUI [1,2])
Order identification number
Item
Auftragsnummer
integer
C1300638 (UMLS CUI [1,1])
C1705175 (UMLS CUI [1,2])
C0199850 (UMLS CUI [1,3])
Urgency
Item
Dringlichkeit
text
C4049774 (UMLS CUI [1,1])
C0199850 (UMLS CUI [1,2])
Recipient
Item
Zielbenutzer
text
C1709854 (UMLS CUI [1,1])
C1706077 (UMLS CUI [1,2])
C0199850 (UMLS CUI [1,3])
Department requesting examination
Item
Leistungsanforderer
text
C1705175 (UMLS CUI [1,1])
C2986180 (UMLS CUI [1,2])
C0019961 (UMLS CUI [1,3])
Department performing examination
Item
Leistungserbringer
text
C0199850 (UMLS CUI [1,1])
C2986180 (UMLS CUI [1,2])
C0019961 (UMLS CUI [1,3])
Requested examination
Item
Angeforderte Leistung
text
C0430022 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Date of examination
Item
Termin der Untersuchung
date
C0011008 (UMLS CUI [1,1])
C0199850 (UMLS CUI [1,2])
Item Group
UFK Brustzentrum, Befund Mammasonografie
C0425770 (UMLS CUI-1)
C0080264 (UMLS CUI-2)
Item
Beurteilbarkeit rechts
integer
C0332306 (UMLS CUI [1,1])
C0425770 (UMLS CUI [1,2])
C0222600 (UMLS CUI [1,3])
Assessability on right side
Code List
Beurteilbarkeit rechts
CL Item
gut (1)
CL Item
eingeschränkt (2)
CL Item
schlecht (3)
Item
Beurteilbarkeit links
integer
C0332306 (UMLS CUI [1,1])
C0425770 (UMLS CUI [1,2])
C0222601 (UMLS CUI [1,3])
Assessability on the left side
Code List
Beurteilbarkeit links
CL Item
gut (1)
CL Item
eingeschränkt (2)
CL Item
schlecht (3)
Item
Parenchymdichte rechts
integer
C1659543 (UMLS CUI [1,1])
C0222600 (UMLS CUI [1,2])
Breast density in right breast
Code List
Parenchymdichte rechts
CL Item
ACR 1 (1)
CL Item
ACR 2 (2)
CL Item
ACR 3 (3)
CL Item
ACR 4 (4)
Item
Parenchymdichte links
integer
C1659543 (UMLS CUI [1,1])
C0222601 (UMLS CUI [1,2])
Breast density in left breast
Code List
Parenchymdichte links
CL Item
ACR 1 (1)
CL Item
ACR 2 (2)
CL Item
ACR 3 (3)
CL Item
ACR 4 (4)
Item
Lymphabflussgebiet rechts
integer
C0398480 (UMLS CUI [1,1])
C0222600 (UMLS CUI [1,2])
Lymphatic drainage right breast
Code List
Lymphabflussgebiet rechts
CL Item
axillär (1)
CL Item
infraklavikulär (2)
CL Item
supraklavikulär (3)
Item
Lymphabflussgebiet links
integer
C0398480 (UMLS CUI [1,1])
C0222601 (UMLS CUI [1,2])
Lymphatic drainage left breast
Code List
Lymphabflussgebiet links
CL Item
axillär (1)
CL Item
infraklavikulär (2)
CL Item
supraklavikulär (3)
Lesion
Item
Herdbefund
boolean
C0221198 (UMLS CUI [1,1])
C0425770 (UMLS CUI [1,2])
Ultrasonographic diagnosis
Item
Sonografische Diagnose
text
C0011900 (UMLS CUI [1,1])
C0080264 (UMLS CUI [1,2])
Item Group
BIRADS Klassifikation
C1511314 (UMLS CUI-1)
C0008902 (UMLS CUI-2)
Item
BI-RADS
integer
C1511314 (UMLS CUI [1])
BI-RADS
Code List
BI-RADS
CL Item
Kategorie 0, eingeschränkt beurteilbar, Karzinomwahrscheinlichkeit unklar, weiter bildgebende Abklärung erforderlich (1)
CL Item
Kategorie 1, unauffällig, Karzinomwahrscheinlichkeit 0%, keine weiteren Maßnahmen, evtl. ergänzend Vergleich mit Mammographie (2)
CL Item
Kategorie 2, gutartig, Karzinomwahrscheinlichkeit 0%, keine Punktion nötig, nur bei Symptomatik (3)
CL Item
Kategorie 3, wahrscheinlich gutartig, Karzinomwahrscheinlichkeit </=2%, kurzfristige Verlaufskontrolle empfohlen, evtl. Punktion (4)
CL Item
Kategorie 4a, gering malignitätsverdächtig, Karzinomwahrscheinlichkeit 2-95%, Stanzbiopsie empfohlen (5)
CL Item
Kategorie 4b, mittelgradig malignitätsverdächtig, Karzinomwahrscheinlichkeit 2-95%, Stanzbiopsie empfohlen (6)
CL Item
Kategorie 4c, hoch malignitätsverdächtig, Karzinomwahrscheinlichkeit 2-95%, Stanzbiopsie empfohlen (7)
CL Item
Kategorie 5, wahrscheinlich maligne, Karzinomwahrscheinlichkeit >95%, Abklärung erforderlich (8)
CL Item
Kategorie 6, histologisch gesicherte Malignität (9)
Breast finding
Item
Befund
text
C0425770 (UMLS CUI [1])
Evaluation breast finding
Item
Beurteilung
text
C0220825 (UMLS CUI [1,1])
C0425770 (UMLS CUI [1,2])
Recommendation
Item
Empfehlung
text
C0034866 (UMLS CUI [1,1])
C0425770 (UMLS CUI [1,2])
Date of finding
Item
Befundet am
date
C0011008 (UMLS CUI [1,1])
C0425770 (UMLS CUI [1,2])
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