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3927

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

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Versions (1)
  1. 5/15/13 5/15/13 -
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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 cancer conference 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
    Gespräch nach Tumorkonferenz
    Description

    Gespräch nach Tumorkonferenz

    date
    Description

    Patientin informiert

    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
    Informed consent for decision cancer conference obtained
    Description

    mit Empfehlung einverstanden

    Data type

    boolean

    Alias
    Code-1
    Informed consent obtained
    UMLS CUI-1
    C0514044
    LOINC-1
    MTHU008888
    Code-2
    Cancer conference
    UMLS CUI-2
    C0805438
    LOINC-2
    MTHU010336
    Code-3
    Decision
    UMLS CUI-3
    C0679006
    change of cancer conference decision
    Description

    wenn nein, folgende Abweichungen

    Data type

    string

    Alias
    Code-1
    Change
    UMLS CUI-1
    C0392747
    SNOMED CT-1
    243326001
    Code-2
    Decision
    UMLS CUI-2
    C0679006
    Code-3
    Cancer conference
    UMLS CUI-3
    C0805438
    LOINC-3
    MTHU010336
    planned procedures
    Description

    weitere Maßnahmen wurden eingeleitet

    Data type

    integer

    Alias
    Code-1
    Therapeutic procedure
    UMLS CUI-1
    C0087111
    SNOMED CT-1
    277132007
    MedDRA-1
    10053757
    LOINC-1
    MTHU008880
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    Patient informed systemic therapy
    Description

    Aufklärung über Systemtherapie

    Data type

    boolean

    Alias
    Code-1
    Informing patient (procedure)
    UMLS CUI-1
    C0588446
    SNOMED CT-1
    310866003
    Code-2
    Systemic Therapy
    UMLS CUI-2
    C1515119
    Patient informed endocrin therapy
    Description

    Aufklärung über Systemtherapie: endokrine Therapie

    Data type

    boolean

    Alias
    Code-1
    Informing patient (procedure)
    UMLS CUI-1
    C0588446
    SNOMED CT-1
    310866003
    Code-2
    Endocrine Therapy
    UMLS CUI-2
    C0279025
    SNOMED CT-2
    169413002
    MedDRA-2
    10065646
    Patient informed chemotherapy
    Description

    Aufklärung über Systemtherapie: Chemotherapie

    Data type

    boolean

    Alias
    Code-1
    Informing patient (procedure)
    UMLS CUI-1
    C0588446
    SNOMED CT-1
    310866003
    Code-2
    Chemotherapy Regimen
    UMLS CUI-2
    C0392920
    SNOMED CT-2
    69960004
    MedDRA-2
    10061758
    Patient informed immunotherapy
    Description

    Aufklärung über Systemtherapie: Herceptin

    Data type

    boolean

    Alias
    Code-1
    Informing patient (procedure)
    UMLS CUI-1
    C0588446
    SNOMED CT-1
    310866003
    Code-2
    Immunotherapy
    UMLS CUI-2
    C0021083
    SNOMED CT-2
    76334006
    Prescriptions endocrine therapy
    Description

    Rp. Antihormonelle Therapie

    Data type

    boolean

    Alias
    Code-1
    Drug Prescriptions
    UMLS CUI-1
    C0033081
    SNOMED CT-1
    182817000
    LOINC-1
    MTHU035094
    Code-2
    Endocrine Therapy
    UMLS CUI-2
    C0279025
    SNOMED CT-2
    169413002
    MedDRA-2
    10065646
    Information endocrine therapy
    Description

    Infobogen endokrine Therapie ausgehändigt

    Data type

    boolean

    Alias
    Code-1
    Information
    UMLS CUI-1
    CL414911
    Code-2
    Endocrine Therapy
    UMLS CUI-2
    C0279025
    SNOMED CT-2
    169413002
    MedDRA-2
    10065646
    Insertion Portacath
    Description

    Organisation Portanlage

    Data type

    boolean

    Alias
    Code-1
    Portacath insertion
    UMLS CUI-1
    C1868856
    Appointment day hospital
    Description

    Termin onkologische Tagesklinik

    Data type

    boolean

    Alias
    Code-1
    Appointment date (finding)
    UMLS CUI-1
    C0585085
    SNOMED CT-1
    185353001
    Code-2
    Day hospital (environment)
    UMLS CUI-2
    C0587438
    SNOMED CT-2
    274516006
    Code-3
    Oncologic (qualifier value)
    UMLS CUI-3
    C0205478
    SNOMED CT-3
    3428006
    Appointment radiation therapy
    Description

    Termin in Strahlentherapie

    Data type

    boolean

    Alias
    Code-1
    Appointment date (finding)
    UMLS CUI-1
    C0585085
    SNOMED CT-1
    185353001
    Code-2
    Therapeutic radiology procedure
    UMLS CUI-2
    C1522449
    SNOMED CT-2
    108290001
    MedDRA-2
    10037794
    Information DMP
    Description

    Info über DMP erfolgt

    Data type

    boolean

    Alias
    Code-1
    Information
    UMLS CUI-1
    CL414911
    Code-2
    Disease management program (regime/therapy)
    UMLS CUI-2
    C1303150
    SNOMED CT-2
    401173007
    other
    Description

    Sonstiges

    Data type

    string

    Alias
    Code-1
    Other
    UMLS CUI-1
    C0205394
    SNOMED CT-1
    74964007
    date physician
    Description

    Datum

    Data type

    date

    Alias
    Code-1
    Signature of responsible attending physician on file
    UMLS CUI-1
    C0807938
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    signature
    Description

    Unterschrift

    Data type

    string

    Alias
    Code-1
    Signature of responsible attending physician on file
    UMLS CUI-1
    C0807938
    Back to the top of the page

    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
    Gespräch nach Tumorkonferenz
    Patientin informiert
    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)
    mit Empfehlung einverstanden
    Item
    Informed consent for decision cancer conference obtained
    boolean
    Informed consent obtained (Code-1)
    C0514044 (UMLS CUI-1)
    MTHU008888 (LOINC-1)
    Cancer conference (Code-2)
    C0805438 (UMLS CUI-2)
    MTHU010336 (LOINC-2)
    Decision (Code-3)
    C0679006 (UMLS CUI-3)
    wenn nein, folgende Abweichungen
    Item
    change of cancer conference decision
    string
    Change (Code-1)
    C0392747 (UMLS CUI-1)
    243326001 (SNOMED CT-1)
    Decision (Code-2)
    C0679006 (UMLS CUI-2)
    Cancer conference (Code-3)
    C0805438 (UMLS CUI-3)
    MTHU010336 (LOINC-3)
    Item
    planned procedures
    integer
    Therapeutic procedure (Code-1)
    C0087111 (UMLS CUI-1)
    277132007 (SNOMED CT-1)
    10053757 (MedDRA-1)
    MTHU008880 (LOINC-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    weitere Maßnahmen wurden eingeleitet
    Code List
    planned procedures
    CL Item
    external therapy (nein, da weitere Therapie extern)
    Extrinsic (Code-1)
    C0205101 (UMLS CUI-1)
    261074009 (SNOMED CT-1)
    Therapeutic procedure (Code-2)
    C0087111 (UMLS CUI-2)
    277132007 (SNOMED CT-2)
    10053757 (MedDRA-2)
    MTHU008880 (LOINC-2)
    CL Item
    not required (nicht erforderlich)
    Requirement (Code-1)
    C1514873 (UMLS CUI-1)
    Negation (Code-2)
    C1518422 (UMLS CUI-2)
    CL Item
    Yes (ja)
    Yes (Code-1)
    C1298907 (UMLS CUI-1)
    373066001 (SNOMED CT-1)
    Aufklärung über Systemtherapie
    Item
    Patient informed systemic therapy
    boolean
    Informing patient (procedure) (Code-1)
    C0588446 (UMLS CUI-1)
    310866003 (SNOMED CT-1)
    Systemic Therapy (Code-2)
    C1515119 (UMLS CUI-2)
    Aufklärung über Systemtherapie: endokrine Therapie
    Item
    Patient informed endocrin therapy
    boolean
    Informing patient (procedure) (Code-1)
    C0588446 (UMLS CUI-1)
    310866003 (SNOMED CT-1)
    Endocrine Therapy (Code-2)
    C0279025 (UMLS CUI-2)
    169413002 (SNOMED CT-2)
    10065646 (MedDRA-2)
    Aufklärung über Systemtherapie: Chemotherapie
    Item
    Patient informed chemotherapy
    boolean
    Informing patient (procedure) (Code-1)
    C0588446 (UMLS CUI-1)
    310866003 (SNOMED CT-1)
    Chemotherapy Regimen (Code-2)
    C0392920 (UMLS CUI-2)
    69960004 (SNOMED CT-2)
    10061758 (MedDRA-2)
    Aufklärung über Systemtherapie: Herceptin
    Item
    Patient informed immunotherapy
    boolean
    Informing patient (procedure) (Code-1)
    C0588446 (UMLS CUI-1)
    310866003 (SNOMED CT-1)
    Immunotherapy (Code-2)
    C0021083 (UMLS CUI-2)
    76334006 (SNOMED CT-2)
    Rp. Antihormonelle Therapie
    Item
    Prescriptions endocrine therapy
    boolean
    Drug Prescriptions (Code-1)
    C0033081 (UMLS CUI-1)
    182817000 (SNOMED CT-1)
    MTHU035094 (LOINC-1)
    Endocrine Therapy (Code-2)
    C0279025 (UMLS CUI-2)
    169413002 (SNOMED CT-2)
    10065646 (MedDRA-2)
    Infobogen endokrine Therapie ausgehändigt
    Item
    Information endocrine therapy
    boolean
    Information (Code-1)
    CL414911 (UMLS CUI-1)
    Endocrine Therapy (Code-2)
    C0279025 (UMLS CUI-2)
    169413002 (SNOMED CT-2)
    10065646 (MedDRA-2)
    Organisation Portanlage
    Item
    Insertion Portacath
    boolean
    Portacath insertion (Code-1)
    C1868856 (UMLS CUI-1)
    Termin onkologische Tagesklinik
    Item
    Appointment day hospital
    boolean
    Appointment date (finding) (Code-1)
    C0585085 (UMLS CUI-1)
    185353001 (SNOMED CT-1)
    Day hospital (environment) (Code-2)
    C0587438 (UMLS CUI-2)
    274516006 (SNOMED CT-2)
    Oncologic (qualifier value) (Code-3)
    C0205478 (UMLS CUI-3)
    3428006 (SNOMED CT-3)
    Termin in Strahlentherapie
    Item
    Appointment radiation therapy
    boolean
    Appointment date (finding) (Code-1)
    C0585085 (UMLS CUI-1)
    185353001 (SNOMED CT-1)
    Therapeutic radiology procedure (Code-2)
    C1522449 (UMLS CUI-2)
    108290001 (SNOMED CT-2)
    10037794 (MedDRA-2)
    Info über DMP erfolgt
    Item
    Information DMP
    boolean
    Information (Code-1)
    CL414911 (UMLS CUI-1)
    Disease management program (regime/therapy) (Code-2)
    C1303150 (UMLS CUI-2)
    401173007 (SNOMED CT-2)
    Sonstiges
    Item
    other
    string
    Other (Code-1)
    C0205394 (UMLS CUI-1)
    74964007 (SNOMED CT-1)
    Datum
    Item
    date physician
    date
    Signature of responsible attending physician on file (Code-1)
    C0807938 (UMLS CUI-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    Unterschrift
    Item
    signature
    string
    Signature of responsible attending physician on file (Code-1)
    C0807938 (UMLS CUI-1)
    Back to the top of the page 

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