ID

4075

Beschrijving

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

Trefwoorden

EHR

D016429

D009369

Routine documentation

C50.9

D010336

07-08-13 07-08-13 -

Geüploaded op

7 augustus 2013

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy

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HIS pathology documtation cancer conference breast cancer

model
Details

HIS

1 Formulieren

StudyEvent: HIS
1. HIS

Admininstrative Daten

Beschrijving

Admininstrative Daten

Patient surname

Beschrijving

Name

Datatype

string

Alias

UMLS CUI-1: C0421448

SNOMED CT-1: 184096005

Patient forename

Beschrijving

Vorname

Datatype

string

Alias

UMLS CUI-1: C0421447

SNOMED CT-1: 184095009

Patient title

Beschrijving

Titel

Datatype

string

Alias

Code-1: Patient title (observable entity)

UMLS CUI-1: C0421450

SNOMED CT-1: 184098006

former Patient name

Beschrijving

früherer Name

Datatype

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

Beschrijving

Geburtsdatum

Datatype

date

Alias

UMLS CUI-1: C0421451

SNOMED CT-1: 184099003

patient age

Beschrijving

Alter

Datatype

integer

Alias

Code-1: patient age

UMLS CUI-1: CL386174

Ethnicity / related nationality data

Beschrijving

Nationalität

Datatype

string

Alias

UMLS CUI-1: C0438960

SNOMED CT-1: 186034007

Code-2: Patients

UMLS CUI-2: C0030705

SNOMED CT-2: 116154003

Street Address

Beschrijving

Adresse

Datatype

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

Beschrijving

PLZ

Datatype

integer

Alias

UMLS CUI-1: C0421454

SNOMED CT-1: 184102003

City of residence

Beschrijving

Stadt

Datatype

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

Beschrijving

Pathologie-Dokumentation für FK Tumorboard

Histopathology-number

Beschrijving

Einsendenummern

Datatype

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

Beschrijving

eingesandte Präparate

Datatype

string

Alias

Code-1: Specimen

UMLS CUI-1: C0370003

SNOMED CT-1: 123038009

LOINC-1: MTHU010726

Specimen with pathologic finding

Beschrijving

eingesandte Präparate mit pathologischem Ergebnis

Datatype

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

Beschrijving

Ergebnis Pathologie

Datatype

string

Alias

Code-1: Histologic Type

UMLS CUI-1: C0449574

SNOMED CT-1: 263541007

LOINC-1: MTHU020048

Pathologic TNM

Beschrijving

Pathologic TNM

Generic tumor staging descriptor

Beschrijving

(y/r)

Datatype

integer

Alias

Code-1: Generic tumor staging descriptor (tumor staging)

UMLS CUI-1: C0475266

SNOMED CT-1: 258233007

Tumor staging descriptor y (y)

Tumor staging descriptor r (r)

pT Stage

Beschrijving

Datatype

string

Alias

Code-1: pT category finding (finding)

UMLS CUI-1: C1272834

SNOMED CT-1: 385385001

pN - Regional lymph node stage

Beschrijving

Datatype

string

Alias

Code-1: pN category finding (finding)

UMLS CUI-1: C1272833

SNOMED CT-1: 385381005

Number of lymph nodes involved by malignant neoplasm

Beschrijving

Anzahl befallener LK

Datatype

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

Beschrijving

Anzahl LK gesamt

Datatype

integer

Alias

UMLS CUI-1: C2733494

SNOMED CT-1: 444025001

Number of sentinel lymph nodes involved

Beschrijving

Anzahl befallener SN-LK

Datatype

integer

Alias

Code-1: Sentinel Lymph Node

UMLS CUI-1: C0677944

SNOMED CT-1: 330469005

Number of sentinel lymph nodes examined

Beschrijving

Anzahl SN-LK gesamt

Datatype

integer

Alias

UMLS CUI-1: C2733493

SNOMED CT-1: 444411008

pM Stage

Beschrijving

Datatype

string

Alias

Code-1: pM category (observable entity)

UMLS CUI-1: C1269798

SNOMED CT-1: 371497001

Lymph vessel invasion

Beschrijving

Datatype

string

Alias

Code-1: Lymphatic (small vessel) tumor invasion finding (finding)

UMLS CUI-1: C1272791

SNOMED CT-1: 385414009

Venous Invasion

Beschrijving

Datatype

string

Alias

UMLS CUI-1: C1710625

Perineural Invasion

Beschrijving

Datatype

string

Alias

Code-1: Perineural invasion finding

UMLS CUI-1: C1300724

SNOMED CT-1: 396394004

Histologic Grade

Beschrijving

Datatype

string

Alias

UMLS CUI-1: C0919553

SNOMED CT-1: 371469007

Residual tumor stage

Beschrijving

Datatype

string

Alias

Code-1: Residual tumor stage (observable entity)

UMLS CUI-1: C0475286

SNOMED CT-1: 17964000

safety margin Noninfiltrating Intraductal Carcinoma

Beschrijving

RIS

Datatype

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

Beschrijving

Datatype

integer

Alias

Code-1: Status of estrogen receptors of neoplasm (observable entity)

UMLS CUI-1: C2919271

SNOMED CT-1: 445028008

progesterone receptor

Beschrijving

Datatype

integer

Alias

Code-1: Status of progesterone receptors of neoplasm (observable entity)

UMLS CUI-1: C2919590

SNOMED CT-1: 445029000

Ki-67 Antigen

Beschrijving

MIB1

Datatype

integer

Alias

Code-1: Ki-67 Antigen

UMLS CUI-1: C0208804

LOINC-1: MTHU014806

Her-2/neu

Beschrijving

HER2/neu

Datatype

integer

Alias

Code-1: Her2/Neu Status

UMLS CUI-1: C1512413

CISH

Beschrijving

CISH

Datatype

integer

Alias

Code-1: Cytokine-Inducible SH2-Containing Protein

UMLS CUI-1: C0299250

postive (positiv)

negative (negativ)

Histology

Beschrijving

Tumortyp

Datatype

string

Alias

Code-1: ICDO3 Morphology Axis

UMLS CUI-1: CL364362

Code-2: Free Text Format

UMLS CUI-2: C2348713

Histology ICD-O-3

Beschrijving

Histologie ICD-0-3

Datatype

string

Alias

Code-1: ICDO3 Morphology Axis

UMLS CUI-1: CL364362

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Similar models

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HIS

1 Formulieren

StudyEvent: HIS
1. HIS

Name

Type

Description | Question | Decode (Coded Value)

Datatype

Alias

Admininstrative Daten

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)

Pathologie-Dokumentation für FK Tumorboard

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)

Pathologische TNM-Stadium

Item Group

Pathologic TNM

(y/r)

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)

Item

pT Stage

string

pT category finding (finding) (Code-1)
C1272834 (UMLS CUI-1)
385385001 (SNOMED CT-1)

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)

Item

pM Stage

string

pM category (observable entity) (Code-1)
C1269798 (UMLS CUI-1)
371497001 (SNOMED CT-1)

Item

Lymph vessel invasion

string

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

Item

Venous Invasion

string

C1710625 (UMLS CUI-1)

Item

Perineural Invasion

string

Perineural invasion finding (Code-1)
C1300724 (UMLS CUI-1)
396394004 (SNOMED CT-1)

Item

Histologic Grade

string

C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)

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)

Item

Estrogen Receptor

integer

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

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)

CISH

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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Model Commentaren :

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Item Commentaren voor :

HIS pathology documtation cancer conference breast cancer

HIS

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