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4075

Beschreibung

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

Stichworte

  1. 8/7/13 8/7/13 -
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August 7, 2013

DOI

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Creative Commons BY-NC 3.0 Legacy

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    HIS pathology documtation cancer conference breast cancer

    1. StudyEvent: HIS
      1. HIS
    Admininstrative Daten
    Beschreibung

    Admininstrative Daten

    Patient surname
    Beschreibung

    Name

    Datentyp

    string

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

    Vorname

    Datentyp

    string

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

    Titel

    Datentyp

    string

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

    früherer Name

    Datentyp

    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
    Beschreibung

    Geburtsdatum

    Datentyp

    date

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

    Alter

    Datentyp

    integer

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

    Nationalität

    Datentyp

    string

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

    Adresse

    Datentyp

    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
    Beschreibung

    PLZ

    Datentyp

    integer

    Alias
    UMLS CUI-1
    C0421454
    SNOMED CT-1
    184102003
    City of residence
    Beschreibung

    Stadt

    Datentyp

    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
    Beschreibung

    Pathologie-Dokumentation für FK Tumorboard

    Histopathology-number
    Beschreibung

    Einsendenummern

    Datentyp

    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
    Beschreibung

    eingesandte Präparate

    Datentyp

    string

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

    eingesandte Präparate mit pathologischem Ergebnis

    Datentyp

    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
    Beschreibung

    Ergebnis Pathologie

    Datentyp

    string

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

    Pathologic TNM

    Generic tumor staging descriptor
    Beschreibung

    (y/r)

    Datentyp

    integer

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

    pT

    Datentyp

    string

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

    pN

    Datentyp

    string

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

    Anzahl befallener LK

    Datentyp

    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
    Beschreibung

    Anzahl LK gesamt

    Datentyp

    integer

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

    Anzahl befallener SN-LK

    Datentyp

    integer

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

    Anzahl SN-LK gesamt

    Datentyp

    integer

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

    M

    Datentyp

    string

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

    L

    Datentyp

    string

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

    V

    Datentyp

    string

    Alias
    UMLS CUI-1
    C1710625
    Perineural Invasion
    Beschreibung

    Pn

    Datentyp

    string

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

    G

    Datentyp

    string

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

    R

    Datentyp

    string

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

    RIS

    Datentyp

    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
    Beschreibung

    ER

    Datentyp

    integer

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

    PR

    Datentyp

    integer

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

    MIB1

    Datentyp

    integer

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

    HER2/neu

    Datentyp

    integer

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

    CISH

    Datentyp

    integer

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

    Tumortyp

    Datentyp

    string

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

    Histologie ICD-0-3

    Datentyp

    string

    Alias
    Code-1
    ICDO3 Morphology Axis
    UMLS CUI-1
    CL364362

    Ähnliche Modelle

    1. StudyEvent: HIS
      1. HIS
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    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)
    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)
    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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