ID

3893

Description

HIS pathology report - biopsy prostate cancer

Keywords

Versions (1)
  1. 5/15/13 5/15/13 -
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May 15, 2013

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License

Creative Commons BY-NC 3.0 Legacy
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HIS pathology report - biopsy prostate cancer

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
Admininstrative Daten
Description

Admininstrative Daten

Patient surname
Description

Name

Data type

string

Alias
UMLS CUI-1
C0421448
SNOMED CT-1
184096005
Patient forename
Description

Vorname

Data type

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patient title
Description

Titel

Data type

string

Alias
Code-1
Patient title (observable entity)
UMLS CUI-1
C0421450
SNOMED CT-1
184098006
former Patient name
Description

früherer Name

Data type

string

Alias
Code-1
Previous
UMLS CUI-1
C0205156
SNOMED CT-1
9130008
Code-2
Patient name (observable entity)
UMLS CUI-2
C1299487
SNOMED CT-2
371484003
Patient date of birth
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
patient age
Description

Alter

Data type

integer

Alias
Code-1
patient age
UMLS CUI-1
CL386174
Ethnicity / related nationality data
Description

Nationalität

Data type

string

Alias
UMLS CUI-1
C0438960
SNOMED CT-1
186034007
Code-2
Patients
UMLS CUI-2
C0030705
SNOMED CT-2
116154003
Street Address
Description

Adresse

Data type

string

Alias
UMLS CUI-1
C1301826
SNOMED CT-1
398099009
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
Patient postal code
Description

PLZ

Data type

integer

Alias
UMLS CUI-1
C0421454
SNOMED CT-1
184102003
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
City of residence
Description

Stadt

Data type

string

Alias
UMLS CUI-1
C2316883
SNOMED CT-1
433178008
Code-2
Patient address
UMLS CUI-2
C0421449
SNOMED CT-2
184097001
Case Identifier
Description

Fallnummer

Data type

integer

Alias
Code-1
Case - situation (qualifier value)
UMLS CUI-1
C0868928
SNOMED CT-1
398241000
Code-2
Identifier
UMLS CUI-2
C0600091
SNOMED CT-2
118522005
Tumorhistologie
Description

Tumorhistologie

General pathology department
Description

Pathologisches Institut

Data type

string

Alias
UMLS CUI-1
C0587490
SNOMED CT-1
309953001
Histopathology-number
Description

Histologie-Einsendenummer

Data type

string

Alias
Item-Info
must_have
Code-1
Histopathology
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Nummer/Identifier
UMLS CUI-2
C0600091
SNOMED CT-2
118522005
LOINC-2
MTHU003116
Admission Information
Description

Aufnahme-Nr. WHK

Data type

string

Alias
Code-1
Admission Information
UMLS CUI-1
C2599639
Histopathology
Description

Histopathology

Date of Histology
Description

Histologie-Datum

Data type

date

Alias
Item-Info
must_have
Code-1
Date of pathology report (observable entity)
UMLS CUI-1
C1302659
SNOMED CT-1
399737008
Time of entry
Description

Eingangszeit

Data type

string

Alias
Code-1
Date of entry
UMLS CUI-1
C1978797
LOINC-1
MTHU026971
Histology ICD-O-3
Description

Histologie ICD-0-3

Data type

string

Alias
Item-Info
must_have
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Histopathology
Description

sonstige Histologie

Data type

string

Alias
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
Code-3
Biopsy
UMLS CUI-3
C0005558
SNOMED CT-3
86273004
MedDRA-3
10004720
LOINC-3
MTHU028106
Histology ICD-O-3
Description

mit ICD-0-3

Data type

string

Alias
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
Code-3
Biopsy
UMLS CUI-3
C0005558
SNOMED CT-3
86273004
MedDRA-3
10004720
LOINC-3
MTHU028106
Stanzen
Description

Stanzen

Biopsy Site
Description

Ort der Stanze

Data type

integer

Alias
UMLS CUI-1
C1301128
SNOMED CT-1
396991001
Stanze
Description

Stanze

executed
Description

durchgeführt

Data type

boolean

Alias
Code-1
Execution
UMLS CUI-1
C1705848
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
No tumor present in specimen
Description

kein Tumornachweis

Data type

boolean

Alias
Code-1
No tumor present in specimen (finding)
UMLS CUI-1
C1300994
SNOMED CT-1
396796000
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Total Gleason Score for Prostate Cancer
Description

Gleason-Summe

Data type

integer

Alias
UMLS CUI-1
C1273607
SNOMED CT-1
384997002
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Primary Gleason Pattern
Description

Gleason-1

Data type

integer

Alias
UMLS CUI-1
C1273604
SNOMED CT-1
384994009
LOINC-1
MTHU020049
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Secondary Gleason Pattern
Description

Gleason-2

Data type

integer

Alias
UMLS CUI-1
C1273605
SNOMED CT-1
384995005
LOINC-1
MTHU020050
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma
Description

Tumor in % der Stanze

Data type

string

Alias
Code-1
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma (observable entity)
UMLS CUI-1
C1272841
SNOMED CT-1
385396009
Length of specimen
Description

Länge (in mm)

Data type

string

Alias
Code-1
Length of core in specimen obtained by needle biopsy (observable entity)
UMLS CUI-1
C1302538
SNOMED CT-1
99598003
Other useful information
Description

sonstige Information

Data type

string

Alias
UMLS CUI-1
C2598196
LOINC-1
MTHU029932
Atypical Small Acinar Proliferation of the Prostate Gland
Description

ASAP

Data type

boolean

Alias
UMLS CUI-1
C1332353
High Grade Prostatic Intraepithelial Neoplasia
Description

PIN-HG

Data type

boolean

Alias
UMLS CUI-1
C1168327
SNOMED CT-1
446711009
prostatitis
Description

Prostatis

Data type

boolean

Alias
UMLS CUI-1
C0033581
SNOMED CT-1
9713002
MedDRA-1
10036978
ICD-10-CM-1
N41.9
ICD-9-CM-1
601.9
Necrosis
Description

Nekrosen

Data type

boolean

Alias
UMLS CUI-1
C0027540
SNOMED CT-1
6574001
MedDRA-1
10028851
Seminal vesicle invasion
Description

Samenblaseninfiltration

Data type

boolean

Alias
Code-1
Seminal vesicle invasion by tumor present (finding)
UMLS CUI-1
C1268952
SNOMED CT-1
372294007
extraprostatic extension
Description

extraprostat. Ausbreitung

Data type

boolean

Alias
Code-1
Extraprostatic extension of tumor present (finding)
UMLS CUI-1
C1276734
SNOMED CT-1
372306004
Perineural invasion
Description

Perineuralscheideninvasion

Data type

boolean

Alias
Code-1
Perineural invasion finding
UMLS CUI-1
C1300724
SNOMED CT-1
396394004
TP63 protein
Description

p63 (negativ)

Data type

boolean

Alias
Code-1
TP63 protein, human
UMLS CUI-1
C1431519
Code-2
Negative Finding
UMLS CUI-2
C0205160
SNOMED CT-2
260385009
Alpha-Methylacyl-CoA Racemase
Description

AMACR (positiv)

Data type

boolean

Alias
UMLS CUI-1
C0666209
SNOMED CT-1
130879000
Code-2
Positive Finding
UMLS CUI-2
C1446409
SNOMED CT-2
10828004
Site of distant metastasis
Description

Site of distant metastasis

Site of distant metastasis
Description

Lokalisation 1

Data type

string

Alias
Code-1
Site of distant metastasis (observable entity)
UMLS CUI-1
C0807944
SNOMED CT-1
385421009
LOINC-1
MTHU010380
Date in time
Description

Datum

Data type

date

Alias
Code-1
Date of diagnosis (observable entity)
UMLS CUI-1
C2316983
SNOMED CT-1
432213005
LOINC-1
MTHU038128
Code-2
Distant Metastasis
UMLS CUI-2
CL278860
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Similar models

HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Admininstrative Daten
Name
Item
Patient surname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patient forename
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
Titel
Item
Patient title
string
Patient title (observable entity) (Code-1)
C0421450 (UMLS CUI-1)
184098006 (SNOMED CT-1)
früherer Name
Item
former Patient name
string
Previous (Code-1)
C0205156 (UMLS CUI-1)
9130008 (SNOMED CT-1)
Patient name (observable entity) (Code-2)
C1299487 (UMLS CUI-2)
371484003 (SNOMED CT-2)
Geburtsdatum
Item
Patient date of birth
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Alter
Item
patient age
integer
patient age (Code-1)
CL386174 (UMLS CUI-1)
Nationalität
Item
Ethnicity / related nationality data
string
C0438960 (UMLS CUI-1)
186034007 (SNOMED CT-1)
Patients (Code-2)
C0030705 (UMLS CUI-2)
116154003 (SNOMED CT-2)
Adresse
Item
Street Address
string
C1301826 (UMLS CUI-1)
398099009 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
PLZ
Item
Patient postal code
integer
C0421454 (UMLS CUI-1)
184102003 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
Stadt
Item
City of residence
string
C2316883 (UMLS CUI-1)
433178008 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)
Fallnummer
Item
Case Identifier
integer
Case - situation (qualifier value) (Code-1)
C0868928 (UMLS CUI-1)
398241000 (SNOMED CT-1)
Identifier (Code-2)
C0600091 (UMLS CUI-2)
118522005 (SNOMED CT-2)
Item Group
Tumorhistologie
Pathologisches Institut
Item
General pathology department
string
C0587490 (UMLS CUI-1)
309953001 (SNOMED CT-1)
Histologie-Einsendenummer
Item
Histopathology-number
string
must_have (Item-Info)
Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Nummer/Identifier (Code-2)
C0600091 (UMLS CUI-2)
118522005 (SNOMED CT-2)
MTHU003116 (LOINC-2)
Aufnahme-Nr. WHK
Item
Admission Information
string
Admission Information (Code-1)
C2599639 (UMLS CUI-1)
Item Group
Histopathology
Histologie-Datum
Item
Date of Histology
date
must_have (Item-Info)
Date of pathology report (observable entity) (Code-1)
C1302659 (UMLS CUI-1)
399737008 (SNOMED CT-1)
Eingangszeit
Item
Time of entry
string
Date of entry (Code-1)
C1978797 (UMLS CUI-1)
MTHU026971 (LOINC-1)
Histologie ICD-0-3
Item
Histology ICD-O-3
string
must_have (Item-Info)
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
sonstige Histologie
Item
Histopathology
string
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
Biopsy (Code-3)
C0005558 (UMLS CUI-3)
86273004 (SNOMED CT-3)
10004720 (MedDRA-3)
MTHU028106 (LOINC-3)
mit ICD-0-3
Item
Histology ICD-O-3
string
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
Biopsy (Code-3)
C0005558 (UMLS CUI-3)
86273004 (SNOMED CT-3)
10004720 (MedDRA-3)
MTHU028106 (LOINC-3)
Item Group
Stanzen
Item
Biopsy Site
integer
C1301128 (UMLS CUI-1)
396991001 (SNOMED CT-1)
Ort der Stanze
Code List
Biopsy Site
CL Item
right apical medial (RAM)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Apical (Code-2)
C0205111 (UMLS CUI-2)
43674008 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
right apical lateral (RAL)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Apical (Code-2)
C0205112 (UMLS CUI-2)
43674009 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
right concentric medial (RMM)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Concentric (Code-2)
C0439744 (UMLS CUI-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
right concentric lateral (RML)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Concentric (Code-2)
C0439745 (UMLS CUI-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
right basal medial (RBM)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Basal (Code-2)
C0205112 (UMLS CUI-2)
57195005 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
right basal lateral (RBL)
Right (Code-1)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
Basal (Code-2)
C0205113 (UMLS CUI-2)
57195006 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
left apical medial (LAM)
Left (Code-1)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Apical (Code-2)
C0205111 (UMLS CUI-2)
43674008 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
left apical lateral (LAL)
Left (Code-1)
C0205092 (UMLS CUI-1)
7771001 (SNOMED CT-1)
Apical (Code-2)
C0205112 (UMLS CUI-2)
43674009 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
left concentric medial (LMM)
Left (Code-1)
C0205093 (UMLS CUI-1)
7771002 (SNOMED CT-1)
Concentric (Code-2)
C0439744 (UMLS CUI-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
left concentric lateral (LML)
Left (Code-1)
C0205094 (UMLS CUI-1)
7771003 (SNOMED CT-1)
Concentric (Code-2)
C0439745 (UMLS CUI-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
left basal medial (LBM)
Left (Code-1)
C0205095 (UMLS CUI-1)
7771004 (SNOMED CT-1)
Basal (Code-2)
C0205112 (UMLS CUI-2)
57195005 (SNOMED CT-2)
Medial (Code-3)
C0205098 (UMLS CUI-3)
255561001 (SNOMED CT-3)
CL Item
left basal lateral (LBL)
Left (Code-1)
C0205096 (UMLS CUI-1)
7771005 (SNOMED CT-1)
Basal (Code-2)
C0205113 (UMLS CUI-2)
57195006 (SNOMED CT-2)
Lateral (Code-3)
C0205093 (UMLS CUI-3)
49370004 (SNOMED CT-3)
CL Item
Add (Zusatz)
Additional (Code-1)
C1524062 (UMLS CUI-1)
MTHU013802 (LOINC-1)
Item Group
Stanze
durchgeführt
Item
executed
boolean
Execution (Code-1)
C1705848 (UMLS CUI-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
kein Tumornachweis
Item
No tumor present in specimen
boolean
No tumor present in specimen (finding) (Code-1)
C1300994 (UMLS CUI-1)
396796000 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-Summe
Item
Total Gleason Score for Prostate Cancer
integer
C1273607 (UMLS CUI-1)
384997002 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-1
Item
Primary Gleason Pattern
integer
C1273604 (UMLS CUI-1)
384994009 (SNOMED CT-1)
MTHU020049 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-2
Item
Secondary Gleason Pattern
integer
C1273605 (UMLS CUI-1)
384995005 (SNOMED CT-1)
MTHU020050 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Tumor in % der Stanze
Item
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma
string
Percentage of prostatic tissue, obtained by needle biopsy, involved by carcinoma (observable entity) (Code-1)
C1272841 (UMLS CUI-1)
385396009 (SNOMED CT-1)
Länge (in mm)
Item
Length of specimen
string
Length of core in specimen obtained by needle biopsy (observable entity) (Code-1)
C1302538 (UMLS CUI-1)
99598003 (SNOMED CT-1)
sonstige Information
Item
Other useful information
string
C2598196 (UMLS CUI-1)
MTHU029932 (LOINC-1)
ASAP
Item
Atypical Small Acinar Proliferation of the Prostate Gland
boolean
C1332353 (UMLS CUI-1)
PIN-HG
Item
High Grade Prostatic Intraepithelial Neoplasia
boolean
C1168327 (UMLS CUI-1)
446711009 (SNOMED CT-1)
Prostatis
Item
prostatitis
boolean
C0033581 (UMLS CUI-1)
9713002 (SNOMED CT-1)
10036978 (MedDRA-1)
N41.9 (ICD-10-CM-1)
601.9 (ICD-9-CM-1)
Nekrosen
Item
Necrosis
boolean
C0027540 (UMLS CUI-1)
6574001 (SNOMED CT-1)
10028851 (MedDRA-1)
Samenblaseninfiltration
Item
Seminal vesicle invasion
boolean
Seminal vesicle invasion by tumor present (finding) (Code-1)
C1268952 (UMLS CUI-1)
372294007 (SNOMED CT-1)
extraprostat. Ausbreitung
Item
extraprostatic extension
boolean
Extraprostatic extension of tumor present (finding) (Code-1)
C1276734 (UMLS CUI-1)
372306004 (SNOMED CT-1)
Perineuralscheideninvasion
Item
Perineural invasion
boolean
Perineural invasion finding (Code-1)
C1300724 (UMLS CUI-1)
396394004 (SNOMED CT-1)
p63 (negativ)
Item
TP63 protein
boolean
TP63 protein, human (Code-1)
C1431519 (UMLS CUI-1)
Negative Finding (Code-2)
C0205160 (UMLS CUI-2)
260385009 (SNOMED CT-2)
AMACR (positiv)
Item
Alpha-Methylacyl-CoA Racemase
boolean
C0666209 (UMLS CUI-1)
130879000 (SNOMED CT-1)
Positive Finding (Code-2)
C1446409 (UMLS CUI-2)
10828004 (SNOMED CT-2)
Item Group
Site of distant metastasis
Lokalisation 1
Item
Site of distant metastasis
string
Site of distant metastasis (observable entity) (Code-1)
C0807944 (UMLS CUI-1)
385421009 (SNOMED CT-1)
MTHU010380 (LOINC-1)
Datum
Item
Date in time
date
Date of diagnosis (observable entity) (Code-1)
C2316983 (UMLS CUI-1)
432213005 (SNOMED CT-1)
MTHU038128 (LOINC-1)
Distant Metastasis (Code-2)
CL278860 (UMLS CUI-2)
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