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ID

3894

Description

documentation standard - breast cancer - gynecology, with friendly permission (Dr. Tio) - kooperatives Brustzentrum Münster, Bereich Senologie an der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe - Leitung: Dr. med. Joke Tio

Keywords

Versions (2)
  1. 5/15/13 5/15/13 -
  2. 9/20/21 9/20/21 -
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May 15, 2013

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Creative Commons BY-NC 3.0 Legacy
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    HIS talk after biopsy breast cancer

    German English

    HIS

    1 forms  
    1. StudyEvent: HIS
      1. HIS
    Patientenaufkleber groß
    Description

    Patientenaufkleber groß

    Admission date
    Description

    Aufnahmedatum

    Data type

    date

    Alias
    Code-1
    Date of admission
    UMLS CUI-1
    C1302393
    SNOMED CT-1
    399423000
    LOINC-1
    MTHU029790
    Patient Identification Number
    Description

    PatientenID

    Data type

    integer

    Alias
    Code-1
    Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal
    UMLS CUI-1
    C2706086
    LOINC-1
    52463-7
    Patient sex
    Description

    Geschlecht

    Data type

    string

    Alias
    UMLS CUI-1
    C0150831
    SNOMED CT-1
    184100006
    Patient surname
    Description

    Nachname

    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 date of birth
    Description

    Geburtsdatum

    Data type

    date

    Alias
    UMLS CUI-1
    C0421451
    SNOMED CT-1
    184099003
    Admission hour
    Description

    Aufnahmezeit

    Data type

    date

    Alias
    Code-1
    Date of admission
    UMLS CUI-1
    C1302393
    SNOMED CT-1
    399423000
    LOINC-1
    MTHU029790
    Code-2
    Hour
    UMLS CUI-2
    C0439227
    SNOMED CT-2
    258702006
    HL7 V3-2
    HR
    Physician admission
    Description

    E-Arzt

    Data type

    string

    Alias
    Code-1
    Admission
    UMLS CUI-1
    C0809949
    Code-2
    Physicians
    UMLS CUI-2
    C0031831
    SNOMED CT-2
    112247003
    LOINC-2
    MTHU010489
    HL7 V3-2
    PHYS
    Patienteninformation
    Description

    Patienteninformation

    date
    Description

    am

    Data type

    date

    Alias
    Code-1
    Visit Date
    UMLS CUI-1
    C1320303
    SNOMED CT-1
    406543005
    responsible person
    Description

    durch Dr.

    Data type

    string

    Alias
    Code-1
    Responsible Person
    UMLS CUI-1
    C1273518
    SNOMED CT-1
    394851003
    Histopathology
    Description

    Histologie

    Data type

    string

    Alias
    Code-1
    Histopathology
    UMLS CUI-1
    C0677043
    SNOMED CT-1
    394597005
    Code-2
    Biopsy
    UMLS CUI-2
    C0005558
    SNOMED CT-2
    86273004
    MedDRA-2
    10004720
    LOINC-2
    MTHU028106
    Operative Surgical Procedures
    Description

    Operative Surgical Procedures

    Excisional Biopsy
    Description

    DE

    Data type

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Excisional Biopsy
    UMLS CUI-1
    C0184921
    SNOMED CT-1
    8889005
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    Breast Conservation Treatment
    Description

    BET

    Data type

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Breast Conservation Treatment
    UMLS CUI-1
    C0917927
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    reconstructive breast conservation treatment
    Description

    onkopl. BET

    Data type

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Plastic Surgical Procedures
    UMLS CUI-1
    C0677616
    SNOMED CT-1
    286553006
    MedDRA-1
    10062082
    Code-2
    Breast Conservation Treatment
    UMLS CUI-2
    C0917927
    Code-3
    Plan
    UMLS CUI-3
    C1301732
    SNOMED CT-3
    397943006
    mastectomy
    Description

    ME

    Data type

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Mastectomy
    UMLS CUI-1
    C0024881
    MedDRA-1
    10026878
    ICD-9-CM-1
    85.4
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    Operative Surgical Procedures
    Description

    geplante Operation II

    Data type

    integer

    Alias
    UMLS CUI-1
    C0543467
    SNOMED CT-1
    387713003
    MedDRA-1
    10042609
    LOINC-1
    MTHU007597
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    Sentinel Lymph Node Biopsy
    Description

    SLN

    Data type

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Sentinel Lymph Node Biopsy
    UMLS CUI-1
    C0796693
    SNOMED CT-1
    396487001
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    Axillary Lymph Node Dissection
    Description

    aLNE

    Data type

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Axillary Lymph Node Dissection
    UMLS CUI-1
    C0193867
    SNOMED CT-1
    234254000
    MedDRA-1
    10068477
    ICD-9-CM-1
    40.23
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    Reconstructive Surgical Procedure
    Description

    Rekonstruktion gewünscht

    Data type

    integer

    Alias
    Code-1
    Reconstructive Surgical Procedures
    UMLS CUI-1
    C0524865
    SNOMED CT-1
    122465003
    LOINC-1
    MTHU010401
    Date of admission
    Description

    stationäre Aufnahme am

    Data type

    date

    Alias
    Code-1
    Date of admission
    UMLS CUI-1
    C1302393
    SNOMED CT-1
    399423000
    LOINC-1
    MTHU029790
    primary surgeon
    Description

    verantwortlicher Operateur

    Data type

    string

    Alias
    Code-1
    primary surgeon
    UMLS CUI-1
    C0808118
    LOINC-1
    MTHU010488
    HL7 V3-1
    PRISURG
    Patienteninformation II
    Description

    Patienteninformation II

    Intention Chemotherpy
    Description

    Intention

    Data type

    integer

    Alias
    Code-Info
    normalized_coding
    Code-1
    Intention
    UMLS CUI-1
    C1283828
    SNOMED CT-1
    367565008
    Code-2
    Chemotherapy Regimen
    UMLS CUI-2
    C0392920
    SNOMED CT-2
    69960004
    MedDRA-2
    10061758
    Code-3
    Plan
    UMLS CUI-3
    C1301732
    SNOMED CT-3
    397943006
    Clinical Trials
    Description

    Studie

    Data type

    string

    Alias
    UMLS CUI-1
    C0008976
    SNOMED CT-1
    110465008
    disease stage
    Description

    Staging

    Data type

    integer

    Alias
    Code-1
    disease stage
    UMLS CUI-1
    C0699749
    X-Ray of Thorax
    Description

    Rö-Thorax

    Data type

    boolean

    Alias
    Code-1
    Radiographic imaging procedure
    UMLS CUI-1
    C1962945
    SNOMED CT-1
    363680008
    MedDRA-1
    10048064
    Code-2
    Thorax
    UMLS CUI-2
    C0817096
    SNOMED CT-2
    51185008
    date X-Ray of Thorax
    Description

    Rö-Thorax

    Data type

    date

    Alias
    Code-1
    Date in time
    UMLS CUI-1
    C0011008
    SNOMED CT-1
    410671006
    LOINC-1
    MTHU021546
    Code-2
    Radiographic imaging procedure
    UMLS CUI-2
    C1962945
    SNOMED CT-2
    363680008
    MedDRA-2
    10048064
    finding X-Ray of Thorax - free text
    Description

    Befund Rö-Thorax

    Data type

    string

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    Radiographic imaging procedure
    UMLS CUI-2
    C1962945
    SNOMED CT-2
    363680008
    MedDRA-2
    10048064
    Code-3
    Free Text Format
    UMLS CUI-3
    C2348713
    finding X-Ray of Thorax
    Description

    Befund II Rö-Thorax

    Data type

    integer

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    Radiographic imaging procedure
    UMLS CUI-2
    C1962945
    SNOMED CT-2
    363680008
    MedDRA-2
    10048064
    Ultrasonography of Abdomen
    Description

    OB-Sono

    Data type

    boolean

    Alias
    Code-1
    Ultrasonography
    UMLS CUI-1
    C0041618
    SNOMED CT-1
    16310003
    MedDRA-1
    10045434
    LOINC-1
    MTHU000076
    CTCAE-1
    12
    Code-2
    Abdomen
    UMLS CUI-2
    C0000726
    SNOMED CT-2
    113345001
    LOINC-2
    MTHU001425
    date Ultrasonography of Abdomen
    Description

    OB-Sono

    Data type

    date

    Alias
    Code-1
    Ultrasonography
    UMLS CUI-1
    C0041618
    SNOMED CT-1
    16310003
    MedDRA-1
    10045434
    LOINC-1
    MTHU000076
    finding Ultrasonography of Abdomen - free text
    Description

    Befund OB-Sono

    Data type

    string

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    Ultrasonography
    UMLS CUI-2
    C0041618
    SNOMED CT-2
    16310003
    MedDRA-2
    10045434
    LOINC-2
    MTHU000076
    Code-3
    Free Text Format
    UMLS CUI-3
    C2348713
    finding Ultrasonography of Abdomen
    Description

    Befund II OB-Sono

    Data type

    integer

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    Ultrasonography
    UMLS CUI-2
    C0041618
    SNOMED CT-2
    16310003
    MedDRA-2
    10045434
    LOINC-2
    MTHU000076
    Scintigraphy
    Description

    Skelett-Szinitigr.

    Data type

    boolean

    Alias
    Code-1
    Radionuclide Imaging
    UMLS CUI-1
    C0034606
    SNOMED CT-1
    399019003
    MedDRA-1
    10061478
    ICD-9-CM-1
    92
    date scintigraphy
    Description

    Skelett-Szinitigr.

    Data type

    date

    Alias
    Code-1
    Radionuclide Imaging
    UMLS CUI-1
    C0034606
    SNOMED CT-1
    399019003
    MedDRA-1
    10061478
    ICD-9-CM-1
    92
    finding scintigraphy - free text
    Description

    Befund Skelett-Szinitigr.

    Data type

    string

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    Radionuclide Imaging
    UMLS CUI-2
    C0034606
    SNOMED CT-2
    399019003
    MedDRA-2
    10061478
    ICD-9-CM-2
    92
    Code-3
    Free Text Format
    UMLS CUI-3
    C2348713
    finding scintigraphy
    Description

    Befund II Skelett-Szinitigr.

    Data type

    integer

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    Radionuclide Imaging
    UMLS CUI-2
    C0034606
    SNOMED CT-2
    399019003
    MedDRA-2
    10061478
    ICD-9-CM-2
    92
    X-Ray Computed Tomography
    Description

    Computertomogr.

    Data type

    boolean

    Alias
    Code-1
    X-Ray Computed Tomography
    UMLS CUI-1
    C0040405
    SNOMED CT-1
    77477000
    MedDRA-1
    10010234
    date X-Ray Computed Tomography
    Description

    Computertomogr.

    Data type

    date

    Alias
    Code-1
    X-Ray Computed Tomography
    UMLS CUI-1
    C0040405
    SNOMED CT-1
    77477000
    MedDRA-1
    10010234
    finding X-Ray Computed Tomography - free text
    Description

    Befund Computertomogr.

    Data type

    string

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    X-Ray Computed Tomography
    UMLS CUI-2
    C0040405
    SNOMED CT-2
    77477000
    MedDRA-2
    10010234
    Code-3
    Free Text Format
    UMLS CUI-3
    C2348713
    finding X-Ray Computed Tomography
    Description

    Befund II Computertomogr.

    Data type

    integer

    Alias
    Code-1
    Finding
    UMLS CUI-1
    C1285578
    SNOMED CT-1
    363787002
    Code-2
    X-Ray Computed Tomography
    UMLS CUI-2
    C0040405
    SNOMED CT-2
    77477000
    MedDRA-2
    10010234
    distant metastasis
    Description

    Metastasen (M1)

    Data type

    string

    Alias
    Code-1
    Distant Metastasis
    UMLS CUI-1
    CL278860
    second opinion desired
    Description

    Patientin wünscht Zweitmeinung

    Data type

    boolean

    Alias
    Code-1
    Second Opinion
    UMLS CUI-1
    C0036524
    Code-2
    desire
    UMLS CUI-2
    C0871633
    place second opinion
    Description

    Ort Zweitmeinung

    Data type

    string

    Alias
    Code-1
    Second Opinion
    UMLS CUI-1
    C0036524
    Code-2
    Place
    UMLS CUI-2
    C0442504
    SNOMED CT-2
    257557008
    Signature
    Description

    Unterschrift

    Data type

    string

    Alias
    Code-1
    Signature of responsible attending physician on file
    UMLS CUI-1
    C0807938
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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
    Patientenaufkleber groß
    Aufnahmedatum
    Item
    Admission date
    date
    Date of admission (Code-1)
    C1302393 (UMLS CUI-1)
    399423000 (SNOMED CT-1)
    MTHU029790 (LOINC-1)
    PatientenID
    Item
    Patient Identification Number
    integer
    Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal (Code-1)
    C2706086 (UMLS CUI-1)
    52463-7 (LOINC-1)
    Geschlecht
    Item
    Patient sex
    string
    C0150831 (UMLS CUI-1)
    184100006 (SNOMED CT-1)
    Nachname
    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)
    Geburtsdatum
    Item
    Patient date of birth
    date
    C0421451 (UMLS CUI-1)
    184099003 (SNOMED CT-1)
    Aufnahmezeit
    Item
    Admission hour
    date
    Date of admission (Code-1)
    C1302393 (UMLS CUI-1)
    399423000 (SNOMED CT-1)
    MTHU029790 (LOINC-1)
    Hour (Code-2)
    C0439227 (UMLS CUI-2)
    258702006 (SNOMED CT-2)
    HR (HL7 V3-2)
    E-Arzt
    Item
    Physician admission
    string
    Admission (Code-1)
    C0809949 (UMLS CUI-1)
    Physicians (Code-2)
    C0031831 (UMLS CUI-2)
    112247003 (SNOMED CT-2)
    MTHU010489 (LOINC-2)
    PHYS (HL7 V3-2)
    Item Group
    Patienteninformation
    am
    Item
    date
    date
    Visit Date (Code-1)
    C1320303 (UMLS CUI-1)
    406543005 (SNOMED CT-1)
    durch Dr.
    Item
    responsible person
    string
    Responsible Person (Code-1)
    C1273518 (UMLS CUI-1)
    394851003 (SNOMED CT-1)
    Histologie
    Item
    Histopathology
    string
    Histopathology (Code-1)
    C0677043 (UMLS CUI-1)
    394597005 (SNOMED CT-1)
    Biopsy (Code-2)
    C0005558 (UMLS CUI-2)
    86273004 (SNOMED CT-2)
    10004720 (MedDRA-2)
    MTHU028106 (LOINC-2)
    Item Group
    Operative Surgical Procedures
    DE
    Item
    Excisional Biopsy
    boolean
    changed_datatype (Code-Info)
    Excisional Biopsy (Code-1)
    C0184921 (UMLS CUI-1)
    8889005 (SNOMED CT-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    BET
    Item
    Breast Conservation Treatment
    boolean
    changed_datatype (Code-Info)
    Breast Conservation Treatment (Code-1)
    C0917927 (UMLS CUI-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    onkopl. BET
    Item
    reconstructive breast conservation treatment
    boolean
    changed_datatype (Code-Info)
    Plastic Surgical Procedures (Code-1)
    C0677616 (UMLS CUI-1)
    286553006 (SNOMED CT-1)
    10062082 (MedDRA-1)
    Breast Conservation Treatment (Code-2)
    C0917927 (UMLS CUI-2)
    Plan (Code-3)
    C1301732 (UMLS CUI-3)
    397943006 (SNOMED CT-3)
    ME
    Item
    mastectomy
    boolean
    changed_datatype (Code-Info)
    Mastectomy (Code-1)
    C0024881 (UMLS CUI-1)
    10026878 (MedDRA-1)
    85.4 (ICD-9-CM-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    geplante Operation II
    Item
    Operative Surgical Procedures
    integer
    C0543467 (UMLS CUI-1)
    387713003 (SNOMED CT-1)
    10042609 (MedDRA-1)
    MTHU007597 (LOINC-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    SLN
    Item
    Sentinel Lymph Node Biopsy
    boolean
    changed_datatype (Code-Info)
    Sentinel Lymph Node Biopsy (Code-1)
    C0796693 (UMLS CUI-1)
    396487001 (SNOMED CT-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    aLNE
    Item
    Axillary Lymph Node Dissection
    boolean
    changed_datatype (Code-Info)
    Axillary Lymph Node Dissection (Code-1)
    C0193867 (UMLS CUI-1)
    234254000 (SNOMED CT-1)
    10068477 (MedDRA-1)
    40.23 (ICD-9-CM-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    Item
    Reconstructive Surgical Procedure
    integer
    Reconstructive Surgical Procedures (Code-1)
    C0524865 (UMLS CUI-1)
    122465003 (SNOMED CT-1)
    MTHU010401 (LOINC-1)
    Rekonstruktion gewünscht
    Code List
    Reconstructive Surgical Procedure
    CL Item
    not required (nicht notwendig)
    Requirement (Code-1)
    C1514873 (UMLS CUI-1)
    Negation (Code-2)
    C1518422 (UMLS CUI-2)
    CL Item
    No (nein, aber Aufklärung erfolgt)
    No (Code-1)
    C1298908 (UMLS CUI-1)
    373067005 (SNOMED CT-1)
    CL Item
    Yes (ja)
    Yes (Code-1)
    C1298907 (UMLS CUI-1)
    373066001 (SNOMED CT-1)
    CL Item
    Expander (Implantat/Expander)
    Insertion of breast tissue expander (Code-1)
    C0177682 (UMLS CUI-1)
    85.95 (ICD-9-CM-1)
    CL Item
    latissimus dorsi muscle flap (Lat. Dorsi)
    Reconstruction of breast using myocutaneous flap of latissimus dorsi muscle (procedure) (Code-1)
    C0405407 (UMLS CUI-1)
    172057008 (SNOMED CT-1)
    CL Item
    Transverse Rectus Abdominis Myocutaneous flap (TRAM)
    extended_coding (Code-Info)
    Breast reconstruction with TRAM flap (procedure) (Code-1)
    C0521240 (UMLS CUI-1)
    70966003 (SNOMED CT-1)
    10044333 (MedDRA-1)
    CL Item
    deep inferior epigastric perforators (DIEP)
    extended_coding (Code-Info)
    DIEP Flap (Code-1)
    C2985549 (UMLS CUI-1)
    stationäre Aufnahme am
    Item
    Date of admission
    date
    Date of admission (Code-1)
    C1302393 (UMLS CUI-1)
    399423000 (SNOMED CT-1)
    MTHU029790 (LOINC-1)
    verantwortlicher Operateur
    Item
    primary surgeon
    string
    primary surgeon (Code-1)
    C0808118 (UMLS CUI-1)
    MTHU010488 (LOINC-1)
    PRISURG (HL7 V3-1)
    Item Group
    Patienteninformation II
    Item
    Intention Chemotherpy
    integer
    normalized_coding (Code-Info)
    Intention (Code-1)
    C1283828 (UMLS CUI-1)
    367565008 (SNOMED CT-1)
    Chemotherapy Regimen (Code-2)
    C0392920 (UMLS CUI-2)
    69960004 (SNOMED CT-2)
    10061758 (MedDRA-2)
    Plan (Code-3)
    C1301732 (UMLS CUI-3)
    397943006 (SNOMED CT-3)
    Intention
    Code List
    Intention Chemotherpy
    CL Item
    Neo-adjuvant - intent  (N = neoadjuvant)
    normalized_coding (Code-Info)
    Neo-adjuvant - intent (qualifier value) (Code-1)
    C1298676 (UMLS CUI-1)
    373847000 (SNOMED CT-1)
    Studie
    Item
    Clinical Trials
    string
    C0008976 (UMLS CUI-1)
    110465008 (SNOMED CT-1)
    Item
    disease stage
    integer
    disease stage (Code-1)
    C0699749 (UMLS CUI-1)
    Staging
    Code List
    disease stage
    CL Item
    Preoperative (präoperativ)
    Preoperative (Code-1)
    C0445204 (UMLS CUI-1)
    262068006 (SNOMED CT-1)
    CL Item
    Postoperative (postoperativ)
    Postoperative (Code-1)
    C0032790 (UMLS CUI-1)
    262061000 (SNOMED CT-1)
    Rö-Thorax
    Item
    X-Ray of Thorax
    boolean
    Radiographic imaging procedure (Code-1)
    C1962945 (UMLS CUI-1)
    363680008 (SNOMED CT-1)
    10048064 (MedDRA-1)
    Thorax (Code-2)
    C0817096 (UMLS CUI-2)
    51185008 (SNOMED CT-2)
    Rö-Thorax
    Item
    date X-Ray of Thorax
    date
    Date in time (Code-1)
    C0011008 (UMLS CUI-1)
    410671006 (SNOMED CT-1)
    MTHU021546 (LOINC-1)
    Radiographic imaging procedure (Code-2)
    C1962945 (UMLS CUI-2)
    363680008 (SNOMED CT-2)
    10048064 (MedDRA-2)
    Befund Rö-Thorax
    Item
    finding X-Ray of Thorax - free text
    string
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    Radiographic imaging procedure (Code-2)
    C1962945 (UMLS CUI-2)
    363680008 (SNOMED CT-2)
    10048064 (MedDRA-2)
    Free Text Format (Code-3)
    C2348713 (UMLS CUI-3)
    Item
    finding X-Ray of Thorax
    integer
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    Radiographic imaging procedure (Code-2)
    C1962945 (UMLS CUI-2)
    363680008 (SNOMED CT-2)
    10048064 (MedDRA-2)
    Befund II Rö-Thorax
    Code List
    finding X-Ray of Thorax
    CL Item
    Normal (unauffällig)
    Normal (Code-1)
    C0205307 (UMLS CUI-1)
    17621005 (SNOMED CT-1)
    CL Item
    Abnormal  (auffällig)
    Abnormal (Code-1)
    C0205161 (UMLS CUI-1)
    263654008 (SNOMED CT-1)
    OB-Sono
    Item
    Ultrasonography of Abdomen
    boolean
    Ultrasonography (Code-1)
    C0041618 (UMLS CUI-1)
    16310003 (SNOMED CT-1)
    10045434 (MedDRA-1)
    MTHU000076 (LOINC-1)
    12 (CTCAE-1)
    Abdomen (Code-2)
    C0000726 (UMLS CUI-2)
    113345001 (SNOMED CT-2)
    MTHU001425 (LOINC-2)
    OB-Sono
    Item
    date Ultrasonography of Abdomen
    date
    Ultrasonography (Code-1)
    C0041618 (UMLS CUI-1)
    16310003 (SNOMED CT-1)
    10045434 (MedDRA-1)
    MTHU000076 (LOINC-1)
    Befund OB-Sono
    Item
    finding Ultrasonography of Abdomen - free text
    string
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    Ultrasonography (Code-2)
    C0041618 (UMLS CUI-2)
    16310003 (SNOMED CT-2)
    10045434 (MedDRA-2)
    MTHU000076 (LOINC-2)
    Free Text Format (Code-3)
    C2348713 (UMLS CUI-3)
    Item
    finding Ultrasonography of Abdomen
    integer
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    Ultrasonography (Code-2)
    C0041618 (UMLS CUI-2)
    16310003 (SNOMED CT-2)
    10045434 (MedDRA-2)
    MTHU000076 (LOINC-2)
    Befund II OB-Sono
    Code List
    finding Ultrasonography of Abdomen
    CL Item
    Normal (unauffällig)
    Normal (Code-1)
    C0205307 (UMLS CUI-1)
    17621005 (SNOMED CT-1)
    CL Item
    Abnormal  (auffällig)
    Abnormal (Code-1)
    C0205161 (UMLS CUI-1)
    263654008 (SNOMED CT-1)
    Skelett-Szinitigr.
    Item
    Scintigraphy
    boolean
    Radionuclide Imaging (Code-1)
    C0034606 (UMLS CUI-1)
    399019003 (SNOMED CT-1)
    10061478 (MedDRA-1)
    92 (ICD-9-CM-1)
    Skelett-Szinitigr.
    Item
    date scintigraphy
    date
    Radionuclide Imaging (Code-1)
    C0034606 (UMLS CUI-1)
    399019003 (SNOMED CT-1)
    10061478 (MedDRA-1)
    92 (ICD-9-CM-1)
    Befund Skelett-Szinitigr.
    Item
    finding scintigraphy - free text
    string
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    Radionuclide Imaging (Code-2)
    C0034606 (UMLS CUI-2)
    399019003 (SNOMED CT-2)
    10061478 (MedDRA-2)
    92 (ICD-9-CM-2)
    Free Text Format (Code-3)
    C2348713 (UMLS CUI-3)
    Item
    finding scintigraphy
    integer
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    Radionuclide Imaging (Code-2)
    C0034606 (UMLS CUI-2)
    399019003 (SNOMED CT-2)
    10061478 (MedDRA-2)
    92 (ICD-9-CM-2)
    Befund II Skelett-Szinitigr.
    Code List
    finding scintigraphy
    CL Item
    Normal (unauffällig)
    Normal (Code-1)
    C0205307 (UMLS CUI-1)
    17621005 (SNOMED CT-1)
    CL Item
    Abnormal  (auffällig)
    Abnormal (Code-1)
    C0205161 (UMLS CUI-1)
    263654008 (SNOMED CT-1)
    Computertomogr.
    Item
    X-Ray Computed Tomography
    boolean
    X-Ray Computed Tomography (Code-1)
    C0040405 (UMLS CUI-1)
    77477000 (SNOMED CT-1)
    10010234 (MedDRA-1)
    Computertomogr.
    Item
    date X-Ray Computed Tomography
    date
    X-Ray Computed Tomography (Code-1)
    C0040405 (UMLS CUI-1)
    77477000 (SNOMED CT-1)
    10010234 (MedDRA-1)
    Befund Computertomogr.
    Item
    finding X-Ray Computed Tomography - free text
    string
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    X-Ray Computed Tomography (Code-2)
    C0040405 (UMLS CUI-2)
    77477000 (SNOMED CT-2)
    10010234 (MedDRA-2)
    Free Text Format (Code-3)
    C2348713 (UMLS CUI-3)
    Item
    finding X-Ray Computed Tomography
    integer
    Finding (Code-1)
    C1285578 (UMLS CUI-1)
    363787002 (SNOMED CT-1)
    X-Ray Computed Tomography (Code-2)
    C0040405 (UMLS CUI-2)
    77477000 (SNOMED CT-2)
    10010234 (MedDRA-2)
    Befund II Computertomogr.
    Code List
    finding X-Ray Computed Tomography
    CL Item
    Normal (unauffällig)
    Normal (Code-1)
    C0205307 (UMLS CUI-1)
    17621005 (SNOMED CT-1)
    CL Item
    Abnormal  (auffällig)
    Abnormal (Code-1)
    C0205161 (UMLS CUI-1)
    263654008 (SNOMED CT-1)
    Metastasen (M1)
    Item
    distant metastasis
    string
    Distant Metastasis (Code-1)
    CL278860 (UMLS CUI-1)
    Patientin wünscht Zweitmeinung
    Item
    second opinion desired
    boolean
    Second Opinion (Code-1)
    C0036524 (UMLS CUI-1)
    desire (Code-2)
    C0871633 (UMLS CUI-2)
    Ort Zweitmeinung
    Item
    place second opinion
    string
    Second Opinion (Code-1)
    C0036524 (UMLS CUI-1)
    Place (Code-2)
    C0442504 (UMLS CUI-2)
    257557008 (SNOMED CT-2)
    Unterschrift
    Item
    Signature
    string
    Signature of responsible attending physician on file (Code-1)
    C0807938 (UMLS CUI-1)
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