ID

4075

Description

HIS form from Soarian. "Frauenklinik Erlangen" with friendly permission of the gynecology Erlangen (Prof. Beckmann) and the medical informatics department Erlangen (PD Dr. Bürkle)

Keywords

Versions (1)
  1. 8/7/13 8/7/13 -
Uploaded on

August 7, 2013

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Creative Commons BY-NC 3.0 Legacy
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HIS pathology documtation cancer conference breast 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
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
Pathologie-Dokumentation für FK Tumorboard
Description

Pathologie-Dokumentation für FK Tumorboard

Histopathology-number
Description

Einsendenummern

Data type

string

Alias
Code-1
Histopathology
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Identifier
UMLS CUI-2
C0600091
SNOMED CT-2
118522005
LOINC-2
MTHU003116
Specimen
Description

eingesandte Präparate

Data type

string

Alias
Code-1
Specimen
UMLS CUI-1
C0370003
SNOMED CT-1
123038009
LOINC-1
MTHU010726
Specimen with pathologic finding
Description

eingesandte Präparate mit pathologischem Ergebnis

Data type

string

Alias
Code-1
Pathologic findings
UMLS CUI-1
C1317598
LOINC-1
MTHU015584
Code-2
Specimen
UMLS CUI-2
C0370003
SNOMED CT-2
123038009
LOINC-2
MTHU010726
Histopathology
Description

Ergebnis Pathologie

Data type

string

Alias
Code-1
Histologic Type
UMLS CUI-1
C0449574
SNOMED CT-1
263541007
LOINC-1
MTHU020048
Pathologic TNM
Description

Pathologic TNM

Generic tumor staging descriptor
Description

(y/r)

Data type

integer

Alias
Code-1
Generic tumor staging descriptor (tumor staging)
UMLS CUI-1
C0475266
SNOMED CT-1
258233007
pT Stage
Description

pT

Data type

string

Alias
Code-1
pT category finding (finding)
UMLS CUI-1
C1272834
SNOMED CT-1
385385001
pN - Regional lymph node stage
Description

pN

Data type

string

Alias
Code-1
pN category finding (finding)
UMLS CUI-1
C1272833
SNOMED CT-1
385381005
Number of lymph nodes involved by malignant neoplasm
Description

Anzahl befallener LK

Data type

integer

Alias
Code-1
Number of lymph nodes involved by malignant neoplasm (observable entity)
UMLS CUI-1
C2732750
SNOMED CT-1
443527007
Number of lymph nodes examined
Description

Anzahl LK gesamt

Data type

integer

Alias
UMLS CUI-1
C2733494
SNOMED CT-1
444025001
Number of sentinel lymph nodes involved
Description

Anzahl befallener SN-LK

Data type

integer

Alias
Code-1
Sentinel Lymph Node
UMLS CUI-1
C0677944
SNOMED CT-1
330469005
Number of sentinel lymph nodes examined
Description

Anzahl SN-LK gesamt

Data type

integer

Alias
UMLS CUI-1
C2733493
SNOMED CT-1
444411008
pM Stage
Description

M

Data type

string

Alias
Code-1
pM category (observable entity)
UMLS CUI-1
C1269798
SNOMED CT-1
371497001
Lymph vessel invasion
Description

L

Data type

string

Alias
Code-1
Lymphatic (small vessel) tumor invasion finding (finding)
UMLS CUI-1
C1272791
SNOMED CT-1
385414009
Venous Invasion
Description

V

Data type

string

Alias
UMLS CUI-1
C1710625
Perineural Invasion
Description

Pn

Data type

string

Alias
Code-1
Perineural invasion finding
UMLS CUI-1
C1300724
SNOMED CT-1
396394004
Histologic Grade
Description

G

Data type

string

Alias
UMLS CUI-1
C0919553
SNOMED CT-1
371469007
Residual tumor stage
Description

R

Data type

string

Alias
Code-1
Residual tumor stage (observable entity)
UMLS CUI-1
C0475286
SNOMED CT-1
17964000
safety margin Noninfiltrating Intraductal Carcinoma
Description

RIS

Data type

string

Alias
Code-1
Noninfiltrating Intraductal Carcinoma
UMLS CUI-1
C0007124
SNOMED CT-1
86616005
MedDRA-1
10013806
ICD-10-CM-1
D05.1
Code-2
margin of safety
UMLS CUI-2
C0243168
Estrogen Receptor
Description

ER

Data type

integer

Alias
Code-1
Status of estrogen receptors of neoplasm (observable entity)
UMLS CUI-1
C2919271
SNOMED CT-1
445028008
progesterone receptor
Description

PR

Data type

integer

Alias
Code-1
Status of progesterone receptors of neoplasm (observable entity)
UMLS CUI-1
C2919590
SNOMED CT-1
445029000
Ki-67 Antigen
Description

MIB1

Data type

integer

Alias
Code-1
Ki-67 Antigen
UMLS CUI-1
C0208804
LOINC-1
MTHU014806
Her-2/neu
Description

HER2/neu

Data type

integer

Alias
Code-1
Her2/Neu Status
UMLS CUI-1
C1512413
CISH
Description

CISH

Data type

integer

Alias
Code-1
Cytokine-Inducible SH2-Containing Protein
UMLS CUI-1
C0299250
Histology
Description

Tumortyp

Data type

string

Alias
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Free Text Format
UMLS CUI-2
C2348713
Histology ICD-O-3
Description

Histologie ICD-0-3

Data type

string

Alias
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
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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)
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)
Item Group
Pathologie-Dokumentation für FK Tumorboard
Einsendenummern
Item
Histopathology-number
string
Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Identifier (Code-2)
C0600091 (UMLS CUI-2)
118522005 (SNOMED CT-2)
MTHU003116 (LOINC-2)
eingesandte Präparate
Item
Specimen
string
Specimen (Code-1)
C0370003 (UMLS CUI-1)
123038009 (SNOMED CT-1)
MTHU010726 (LOINC-1)
eingesandte Präparate mit pathologischem Ergebnis
Item
Specimen with pathologic finding
string
Pathologic findings (Code-1)
C1317598 (UMLS CUI-1)
MTHU015584 (LOINC-1)
Specimen (Code-2)
C0370003 (UMLS CUI-2)
123038009 (SNOMED CT-2)
MTHU010726 (LOINC-2)
Ergebnis Pathologie
Item
Histopathology
string
Histologic Type (Code-1)
C0449574 (UMLS CUI-1)
263541007 (SNOMED CT-1)
MTHU020048 (LOINC-1)
Item Group
Pathologic TNM
Item
Generic tumor staging descriptor
integer
Generic tumor staging descriptor (tumor staging) (Code-1)
C0475266 (UMLS CUI-1)
258233007 (SNOMED CT-1)
(y/r)
Code List
Generic tumor staging descriptor
CL Item
Tumor staging descriptor y (y)
Tumor staging descriptor y (tumor staging) (Code-1)
C0439147 (UMLS CUI-1)
421755005 (SNOMED CT-1)
CL Item
Tumor staging descriptor r (r)
Tumor staging descriptor r (tumor staging) (Code-1)
C1704239 (UMLS CUI-1)
421188008 (SNOMED CT-1)
pT
Item
pT Stage
string
pT category finding (finding) (Code-1)
C1272834 (UMLS CUI-1)
385385001 (SNOMED CT-1)
pN
Item
pN - Regional lymph node stage
string
pN category finding (finding) (Code-1)
C1272833 (UMLS CUI-1)
385381005 (SNOMED CT-1)
Anzahl befallener LK
Item
Number of lymph nodes involved by malignant neoplasm
integer
Number of lymph nodes involved by malignant neoplasm (observable entity) (Code-1)
C2732750 (UMLS CUI-1)
443527007 (SNOMED CT-1)
Anzahl LK gesamt
Item
Number of lymph nodes examined
integer
C2733494 (UMLS CUI-1)
444025001 (SNOMED CT-1)
Anzahl befallener SN-LK
Item
Number of sentinel lymph nodes involved
integer
Sentinel Lymph Node (Code-1)
C0677944 (UMLS CUI-1)
330469005 (SNOMED CT-1)
Anzahl SN-LK gesamt
Item
Number of sentinel lymph nodes examined
integer
C2733493 (UMLS CUI-1)
444411008 (SNOMED CT-1)
M
Item
pM Stage
string
pM category (observable entity) (Code-1)
C1269798 (UMLS CUI-1)
371497001 (SNOMED CT-1)
L
Item
Lymph vessel invasion
string
Lymphatic (small vessel) tumor invasion finding (finding) (Code-1)
C1272791 (UMLS CUI-1)
385414009 (SNOMED CT-1)
V
Item
Venous Invasion
string
C1710625 (UMLS CUI-1)
Pn
Item
Perineural Invasion
string
Perineural invasion finding (Code-1)
C1300724 (UMLS CUI-1)
396394004 (SNOMED CT-1)
G
Item
Histologic Grade
string
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
R
Item
Residual tumor stage
string
Residual tumor stage (observable entity) (Code-1)
C0475286 (UMLS CUI-1)
17964000 (SNOMED CT-1)
RIS
Item
safety margin Noninfiltrating Intraductal Carcinoma
string
Noninfiltrating Intraductal Carcinoma (Code-1)
C0007124 (UMLS CUI-1)
86616005 (SNOMED CT-1)
10013806 (MedDRA-1)
D05.1 (ICD-10-CM-1)
margin of safety (Code-2)
C0243168 (UMLS CUI-2)
ER
Item
Estrogen Receptor
integer
Status of estrogen receptors of neoplasm (observable entity) (Code-1)
C2919271 (UMLS CUI-1)
445028008 (SNOMED CT-1)
PR
Item
progesterone receptor
integer
Status of progesterone receptors of neoplasm (observable entity) (Code-1)
C2919590 (UMLS CUI-1)
445029000 (SNOMED CT-1)
MIB1
Item
Ki-67 Antigen
integer
Ki-67 Antigen (Code-1)
C0208804 (UMLS CUI-1)
MTHU014806 (LOINC-1)
HER2/neu
Item
Her-2/neu
integer
Her2/Neu Status (Code-1)
C1512413 (UMLS CUI-1)
Item
CISH
integer
Cytokine-Inducible SH2-Containing Protein (Code-1)
C0299250 (UMLS CUI-1)
CISH
Code List
CISH
CL Item
postive (positiv)
Positive Finding (Code-1)
C1446409 (UMLS CUI-1)
10828004 (SNOMED CT-1)
CL Item
negative (negativ)
Negative Finding (Code-1)
C0205160 (UMLS CUI-1)
260385009 (SNOMED CT-1)
Tumortyp
Item
Histology
string
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Histologie ICD-0-3
Item
Histology ICD-O-3
string
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
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