ID

4080

Description

HIS form ORBIS. with friendly permission form gynecology (Dr. Tio) and medical informatics department (Dr. Breil)

Keywords

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

August 7, 2013

DOI

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License

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

German English

HIS

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

Patientenaufkleber groß

Aufnahmedatum
Description

Aufnahmedatum

Data type

date

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

PatientenID

Data type

integer

Alias
Code-1
Patients
UMLS CUI-1
C0030705
SNOMED CT-1
116154003
Code-2
Identification number
UMLS CUI-2
C1300638
SNOMED CT-2
396278008
Geschlecht Patient
Description

Geschlecht

Data type

string

Alias
UMLS CUI-1
C0150831
SNOMED CT-1
184100006
Patienten-Nachname
Description

Nachname

Data type

string

Alias
UMLS CUI-1
C0421448
SNOMED CT-1
184096005
Patienten-Vorname
Description

Vorname

Data type

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patienten-Geburtsdatum
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Aufnahmezeit
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
Einweisender Arzt
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
Tumorkonferenz
Description

Tumorkonferenz

Datum der Konferenz
Description

Datum der Konferenz

Data type

date

Alias
Code-1
Cancer conference:Time Stamp -- Date and Time:Point in time:Cancer.To be specified in another part of the message:Quantitative
UMLS CUI-1
C0804663
LOINC-1
21875-0
Ort der Konferenz
Description

Ort der Konferenz

Data type

string

Alias
Code-1
Place
UMLS CUI-1
C0442504
SNOMED CT-1
257557008
HL7 V3-1
PLC
Code-2
Cancer conference
UMLS CUI-2
C0805438
LOINC-2
MTHU010336
Verantwortliche Person für die Anmeldung
Description

Patient angemeldet durch

Data type

string

Alias
Code-1
Registration
UMLS CUI-1
C1514821
Code-2
Responsible Person
UMLS CUI-2
C1273518
SNOMED CT-2
394851003
Datum der Anmeldung
Description

Datum der Anmeldung

Data type

date

Alias
Code-1
Registration
UMLS CUI-1
C1514821
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
Teilnehmer
Description

Teilnehmer

Data type

integer

Alias
Code-Info
for_compare
Code-1
Conference Participants
UMLS CUI-1
CL106596
Patientendaten
Description

Patientendaten

Status Patient
Description

Patient ist:

Data type

integer

Alias
Code-Info
for_compare
Code-1
Patient status (attribute)
UMLS CUI-1
C0449437
SNOMED CT-1
246097001
Diagnose
Description

Diagnose

Data type

string

Alias
UMLS CUI-1
C0011900
SNOMED CT-1
439401001
LOINC-1
MTHU015826
Karnofsky Index
Description

Karnofsky Index

Data type

string

Alias
Code-1
Karnofsky Performance Status
UMLS CUI-1
C0206065
SNOMED CT-1
273546003
MedDRA-1
10054755
klinische Studie
Description

Studie

Data type

string

Alias
UMLS CUI-1
C0008976
SNOMED CT-1
110465008
Krankheitsverlauf
Description

Krankheitsverlauf

Krankheitsverlauf
Description

Verlauf

Data type

string

Alias
Code-1
Disease Progression
UMLS CUI-1
C0242656
SNOMED CT-1
246453008
MedDRA-1
10061818
LOINC-1
MTHU039942
Code-2
Free Text Format
UMLS CUI-2
C2348713
Pathologie Befund
Description

Pathologie Befund

Kommentar zu den Pathologie Proben
Description

Pathologie Befund

Data type

string

Alias
Code-1
Narrative comments on pathology specimen (observable entity)
UMLS CUI-1
C1444069
SNOMED CT-1
409770001
Frage
Description

Frage

Frage
Description

Fragestellung

Data type

string

Alias
Code-1
Question
UMLS CUI-1
C1522634
Subformular
Description

Subformular

MDT (MIB)
Description

MDT (MIB)

Klinischer Befund vorhanden
Description

kurativ

Data type

boolean

Alias
Code-1
Clinical finding present (situation)
UMLS CUI-1
C1276746
SNOMED CT-1
373573001
MedDRA-1
MTHU019505
Mamma-Screening
Description

Screening

Data type

boolean

Alias
Code-1
Breast Cancer Early Detection
UMLS CUI-1
C0281182
SNOMED CT-1
268547008
Ultraschall-gestütze Biopsie
Description

sonographisch

Data type

boolean

Alias
Code-1
Ultrasound-guided Biopsy
UMLS CUI-1
C0456900
SNOMED CT-1
277667006
Vakuumsaugbiopsie - Sonographie
Description

VSB Sono

Data type

boolean

Alias
Code-1
Vacuum-Assisted Biopsy
UMLS CUI-1
C1710607
Code-2
Ultrasound-guided Biopsy
UMLS CUI-2
C0456900
SNOMED CT-2
277667006
Biopsie bei Mammographie
Description

stereotaktisch MG

Data type

boolean

Alias
Code-1
Mammography and biopsy (procedure)
UMLS CUI-1
C1636774
SNOMED CT-1
418378007
Vakuumsaugbiopsie - Mammographie
Description

VSB MG

Data type

boolean

Alias
Code-1
Vacuum-Assisted Biopsy
UMLS CUI-1
C1710607
Code-2
Mammography and biopsy (procedure)
UMLS CUI-2
C1636774
SNOMED CT-2
418378007
Vakuumsaugbiopsie - MRT
Description

VSB MRT

Data type

boolean

Alias
Code-1
Vacuum-Assisted Biopsy
UMLS CUI-1
C1710607
Code-2
Magnetic resonance imaging guided biopsy (procedure)
UMLS CUI-2
C0456854
SNOMED CT-2
277592004
Datum Pathologie Befund
Description

Histologie der Biopsie

Data type

string

Alias
Code-1
Date of pathology report (observable entity)
UMLS CUI-1
C1302659
SNOMED CT-1
399737008
Histologie Klassifikation (B)
Description

B-Kategorie

Data type

integer

Alias
Code-1
Histologic Type
UMLS CUI-1
C0449574
SNOMED CT-1
263541007
LOINC-1
MTHU020048
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
nicht_kodiert
Description

Korrelation

Data type

integer

Aktion
Description

Aktion

Wiederholung der Biopsie
Description

Wiederholung MIB

Data type

boolean

Alias
Code-1
Repeat
UMLS CUI-1
C0205341
SNOMED CT-1
27582007
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
regülare Vorsorge
Description

reguläre weitere Vorsorge

Data type

boolean

Alias
Code-1
Screening procedure
UMLS CUI-1
C0220908
SNOMED CT-1
275926002
Code-2
Regular
UMLS CUI-2
C0449581
SNOMED CT-2
17854005
geplante Kontrolle
Description

Kontrolle in X Monaten

Data type

boolean

Alias
Code-1
checkup examination
UMLS CUI-1
C0598836
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Monate Check-Up
Description

_ Monate

Data type

integer

Alias
Code-1
month (qualifier value)
UMLS CUI-1
C0439231
SNOMED CT-1
258706009
HL7 V3-1
MO
Check-Up Mammographie
Description

Kontrolle MG

Data type

boolean

Alias
Code-1
Mammography
UMLS CUI-1
C0024671
SNOMED CT-1
71651007
MedDRA-1
10026735
Code-2
checkup examination
UMLS CUI-2
C0598836
Check-Up Sonographie
Description

Konrolle Sono

Data type

boolean

Alias
Code-1
Ultrasonography, Mammary
UMLS CUI-1
C0080264
SNOMED CT-1
47079000
Code-2
checkup examination
UMLS CUI-2
C0598836
Check-Up MRT
Description

Konrolle MRT

Data type

boolean

Alias
Code-1
Magnetic resonance imaging of breast (procedure)
UMLS CUI-1
C0344104
SNOMED CT-1
241615005
Code-2
checkup examination
UMLS CUI-2
C0598836
zusätzliche Biopsie
Description

weiterführende MIB

Data type

boolean

Alias
Code-1
Additional
UMLS CUI-1
C1524062
LOINC-1
MTHU013802
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Excisionsbiopsie
Description

diagnotische Excision

Data type

boolean

Alias
Code-1
Excisional Biopsy
UMLS CUI-1
C0184921
SNOMED CT-1
8889005
onkologische Operation
Description

onkologische OP

Data type

boolean

Alias
Code-1
Surgical Oncology
UMLS CUI-1
C1515090
Audit
Description

Audit

Data type

boolean

Alias
Code-1
Audit
UMLS CUI-1
C1704775
Tumorboardentscheidungen
Description

Tumorboardentscheidungen

Operation
Description

Operation

Data type

boolean

Alias
Code-1
Operative Surgical Procedures
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
Intention
Description

Therapieziel

Data type

integer

Alias
UMLS CUI-1
C1283828
SNOMED CT-1
367565008
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
Chemotherapie
Description

Chemotherapie

Data type

boolean

Alias
Code-1
Chemotherapy Regimen
UMLS CUI-1
C0392920
SNOMED CT-1
69960004
MedDRA-1
10061758
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Intention
Description

Therapieziel

Data type

integer

Alias
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
Bestrahlung
Description

Strahlentherapie

Data type

boolean

Alias
Code-1
Therapeutic radiology procedure
UMLS CUI-1
C1522449
SNOMED CT-1
108290001
MedDRA-1
10037794
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Intention
Description

Therapieziel

Data type

integer

Alias
UMLS CUI-1
C1283828
SNOMED CT-1
367565008
Code-2
Therapeutic radiology procedure
UMLS CUI-2
C1522449
SNOMED CT-2
108290001
MedDRA-2
10037794
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
Hormon- / endokrine Therapie
Description

Hormontherapie

Data type

boolean

Alias
Code-1
Endocrine Therapy
UMLS CUI-1
C0279025
SNOMED CT-1
169413002
MedDRA-1
10065646
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Intention
Description

Therapieziel

Data type

integer

Alias
UMLS CUI-1
C1283828
SNOMED CT-1
367565008
Code-2
Endocrine Therapy
UMLS CUI-2
C0279025
SNOMED CT-2
169413002
MedDRA-2
10065646
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
Immuntherapie
Description

Immuntherapie

Data type

boolean

Alias
Code-1
Immunotherapy
UMLS CUI-1
C0021083
SNOMED CT-1
76334006
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Intention
Description

Therapieziel

Data type

integer

Alias
UMLS CUI-1
C1283828
SNOMED CT-1
367565008
Code-2
Immunotherapy
UMLS CUI-2
C0021083
SNOMED CT-2
76334006
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
Studienprotokoll
Description

Studienprotokoll

Data type

boolean

Alias
UMLS CUI-1
C2348563
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Studienprotokoll - Freitext
Description

Studienprotokoll

Data type

string

Alias
UMLS CUI-1
C2348563
Code-2
Free Text Format
UMLS CUI-2
C2348713
Verlaufskontrolle
Description

Verlaufskontrolle

Data type

boolean

Alias
UMLS CUI-1
C1522577
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Verlaufskontrolle - Freitext
Description

Verlaufskontrolle

Data type

string

Alias
UMLS CUI-1
C1522577
Code-2
Free Text Format
UMLS CUI-2
C2348713
Analgetika
Description

Analgetika

Data type

boolean

Alias
Code-1
Pain management
UMLS CUI-1
C0002766
SNOMED CT-1
278414003
MedDRA-1
10056350
LOINC-1
MTHU031888
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Analgetika - Freitext
Description

Analgetika

Data type

string

Alias
Code-1
Pain management
UMLS CUI-1
C0002766
SNOMED CT-1
278414003
MedDRA-1
10056350
LOINC-1
MTHU031888
Code-2
Free Text Format
UMLS CUI-2
C2348713
andere Empfehlung
Description

sonstige

Data type

boolean

Alias
Code-1
Advising
UMLS CUI-1
C1828381
SNOMED CT-1
424900004
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
andere Empfehlung - Freitext
Description

sonstige

Data type

string

Alias
Code-1
Advising
UMLS CUI-1
C1828381
SNOMED CT-1
424900004
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
Code-3
Free Text Format
UMLS CUI-3
C2348713
Re-Biopsie
Description

Re-Biopsie

Data type

boolean

Alias
Code-1
Repeat
UMLS CUI-1
C0205341
SNOMED CT-1
27582007
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Code-3
Plan
UMLS CUI-3
C1301732
SNOMED CT-3
397943006
Bisphosphonate
Description

Bisphosphonate

Data type

boolean

Alias
Code-1
Diphosphonates
UMLS CUI-1
C0012544
SNOMED CT-1
372907000
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Bisphosphonate - Freitext
Description

Bisphosphonate

Data type

string

Alias
Code-1
Diphosphonates
UMLS CUI-1
C0012544
SNOMED CT-1
372907000
Code-2
Free Text Format
UMLS CUI-2
C2348713
Radioiodtherapie
Description

Radioiodtherapie

Data type

boolean

Alias
Code-1
Iodine 131 therapy (procedure)
UMLS CUI-1
C0454105
SNOMED CT-1
228698009
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Wiedervorstellung nach Diagnostik
Description

Wiedervorstellung nach weiterer Diagnostik

Data type

boolean

Alias
Code-1
Follow-up visit (procedure)
UMLS CUI-1
C0589121
SNOMED CT-1
185389009
Code-2
Post
UMLS CUI-2
C0231290
SNOMED CT-2
237679004
Code-3
diagnostic procedure
UMLS CUI-3
C0430022
SNOMED CT-3
103693007
MedDRA-3
10061816
Active Surveillance
Description

Act. Surveillance

Data type

boolean

Alias
Code-1
Active surveillance (regime/therapy)
UMLS CUI-1
C1827061
SNOMED CT-1
424313000
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Diagnostik notwendig
Description

weitere Diagnostik

Data type

string

Alias
Code-1
diagnostic procedure
UMLS CUI-1
C0430022
SNOMED CT-1
103693007
MedDRA-1
10061816
Code-2
Need
UMLS CUI-2
C0027552
SNOMED CT-2
410525008
Therapie Freitext
Description

Therapie Freitext

Data type

string

Alias
Code-1
Therapeutic procedure
UMLS CUI-1
C0087111
SNOMED CT-1
277132007
MedDRA-1
10053757
LOINC-1
MTHU008880
Code-2
Free Text Format
UMLS CUI-2
C2348713
Datum der Arzt-Unterschrift
Description

Datum

Data type

date

Alias
Code-1
Signature of responsible attending physician on file
UMLS CUI-1
C0807938
SNOMED CT-1
112247003
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
Arzt-Unterschrift
Description

Unterschrift Arzt

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
Aufnahmedatum
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
PatientenID
Item
Patientenidentifikationsnummer
integer
Patients (Code-1)
C0030705 (UMLS CUI-1)
116154003 (SNOMED CT-1)
Identification number (Code-2)
C1300638 (UMLS CUI-2)
396278008 (SNOMED CT-2)
Geschlecht
Item
Geschlecht Patient
string
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
Nachname
Item
Patienten-Nachname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patienten-Vorname
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
Geburtsdatum
Item
Patienten-Geburtsdatum
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Aufnahmezeit
Item
Aufnahmezeit
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
Einweisender Arzt
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
Tumorkonferenz
Datum der Konferenz
Item
Datum der Konferenz
date
Cancer conference:Time Stamp -- Date and Time:Point in time:Cancer.To be specified in another part of the message:Quantitative (Code-1)
C0804663 (UMLS CUI-1)
21875-0 (LOINC-1)
Ort der Konferenz
Item
Ort der Konferenz
string
Place (Code-1)
C0442504 (UMLS CUI-1)
257557008 (SNOMED CT-1)
PLC (HL7 V3-1)
Cancer conference (Code-2)
C0805438 (UMLS CUI-2)
MTHU010336 (LOINC-2)
Patient angemeldet durch
Item
Verantwortliche Person für die Anmeldung
string
Registration (Code-1)
C1514821 (UMLS CUI-1)
Responsible Person (Code-2)
C1273518 (UMLS CUI-2)
394851003 (SNOMED CT-2)
Datum der Anmeldung
Item
Datum der Anmeldung
date
Registration (Code-1)
C1514821 (UMLS CUI-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Item
Teilnehmer
integer
for_compare (Code-Info)
Conference Participants (Code-1)
CL106596 (UMLS CUI-1)
Teilnehmer
Code List
Teilnehmer
CL Item
Gynäkologie (Senologie)
changed_datatype (Code-Info)
Obstetrics and gynecology (clinical specialty) (Code-1)
C1274104 (UMLS CUI-1)
394585009 (SNOMED CT-1)
MTHU000107 (LOINC-1)
CL Item
Radiologie (Radiologie)
changed_datatype (Code-Info)
Radiology Department (Code-1)
C0587500 (UMLS CUI-1)
309964003 (SNOMED CT-1)
CL Item
Nuklearmedizin (Nuklearmedizin)
changed_datatype (Code-Info)
Discipline of Nuclear Medicine (Code-1)
C0028582 (UMLS CUI-1)
394649004 (SNOMED CT-1)
CL Item
Strahlentherapie (Strahlentherapie)
changed_datatype (Code-Info)
Radiation Oncology (Code-1)
C0243005 (UMLS CUI-1)
419815003 (SNOMED CT-1)
CL Item
Pathologie (Pathologie)
changed_datatype (Code-Info)
C0030664 (UMLS CUI-1)
394595002 (SNOMED CT-1)
Item Group
Patientendaten
Item
Status Patient
integer
for_compare (Code-Info)
Patient status (attribute) (Code-1)
C0449437 (UMLS CUI-1)
246097001 (SNOMED CT-1)
Patient ist:
Code List
Status Patient
CL Item
Primärfall (Primärpatient)
Primary (Code-1)
CL414904 (UMLS CUI-1)
Case - situation (qualifier value) (Code-2)
C0868928 (UMLS CUI-2)
398241000 (SNOMED CT-2)
Diagnose
Item
Diagnose
string
C0011900 (UMLS CUI-1)
439401001 (SNOMED CT-1)
MTHU015826 (LOINC-1)
Karnofsky Index
Item
Karnofsky Index
string
Karnofsky Performance Status (Code-1)
C0206065 (UMLS CUI-1)
273546003 (SNOMED CT-1)
10054755 (MedDRA-1)
Studie
Item
klinische Studie
string
C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)
Item Group
Krankheitsverlauf
Verlauf
Item
Krankheitsverlauf
string
Disease Progression (Code-1)
C0242656 (UMLS CUI-1)
246453008 (SNOMED CT-1)
10061818 (MedDRA-1)
MTHU039942 (LOINC-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Item Group
Pathologie Befund
Pathologie Befund
Item
Kommentar zu den Pathologie Proben
string
Narrative comments on pathology specimen (observable entity) (Code-1)
C1444069 (UMLS CUI-1)
409770001 (SNOMED CT-1)
Item Group
Frage
Fragestellung
Item
Frage
string
Question (Code-1)
C1522634 (UMLS CUI-1)
Item Group
Subformular
Item Group
MDT (MIB)
kurativ
Item
Klinischer Befund vorhanden
boolean
Clinical finding present (situation) (Code-1)
C1276746 (UMLS CUI-1)
373573001 (SNOMED CT-1)
MTHU019505 (MedDRA-1)
Screening
Item
Mamma-Screening
boolean
Breast Cancer Early Detection (Code-1)
C0281182 (UMLS CUI-1)
268547008 (SNOMED CT-1)
sonographisch
Item
Ultraschall-gestütze Biopsie
boolean
Ultrasound-guided Biopsy (Code-1)
C0456900 (UMLS CUI-1)
277667006 (SNOMED CT-1)
VSB Sono
Item
Vakuumsaugbiopsie - Sonographie
boolean
Vacuum-Assisted Biopsy (Code-1)
C1710607 (UMLS CUI-1)
Ultrasound-guided Biopsy (Code-2)
C0456900 (UMLS CUI-2)
277667006 (SNOMED CT-2)
stereotaktisch MG
Item
Biopsie bei Mammographie
boolean
Mammography and biopsy (procedure) (Code-1)
C1636774 (UMLS CUI-1)
418378007 (SNOMED CT-1)
VSB MG
Item
Vakuumsaugbiopsie - Mammographie
boolean
Vacuum-Assisted Biopsy (Code-1)
C1710607 (UMLS CUI-1)
Mammography and biopsy (procedure) (Code-2)
C1636774 (UMLS CUI-2)
418378007 (SNOMED CT-2)
VSB MRT
Item
Vakuumsaugbiopsie - MRT
boolean
Vacuum-Assisted Biopsy (Code-1)
C1710607 (UMLS CUI-1)
Magnetic resonance imaging guided biopsy (procedure) (Code-2)
C0456854 (UMLS CUI-2)
277592004 (SNOMED CT-2)
Histologie der Biopsie
Item
Datum Pathologie Befund
string
Date of pathology report (observable entity) (Code-1)
C1302659 (UMLS CUI-1)
399737008 (SNOMED CT-1)
Item
Histologie Klassifikation (B)
integer
Histologic Type (Code-1)
C0449574 (UMLS CUI-1)
263541007 (SNOMED CT-1)
MTHU020048 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
B-Kategorie
Code List
Histologie Klassifikation (B)
CL Item
normales Brustgewebe (B1)
Mammary Gland Tissue (Code-1)
C1521747 (UMLS CUI-1)
Normal (Code-2)
C0205307 (UMLS CUI-2)
17621005 (SNOMED CT-2)
CL Item
benigne (B2)
Benign (Code-1)
C0205183 (UMLS CUI-1)
30807003 (SNOMED CT-1)
CL Item
unklar ob benigne oder maligne (B3)
Neoplasm, Uncertain Whether Benign or Malignant (Code-1)
C0677041 (UMLS CUI-1)
86251006 (SNOMED CT-1)
CL Item
Malignitätsverdacht (B4)
Suspected malignancy (situation) (Code-1)
C0581833 (UMLS CUI-1)
162572001 (SNOMED CT-1)
CL Item
DCIS (B5a)
Noninfiltrating Intraductal Carcinoma (Code-1)
C0007124 (UMLS CUI-1)
86616005 (SNOMED CT-1)
10013806 (MedDRA-1)
D05.1 (ICD-10-CM-1)
CL Item
Invasive Karzinom (B5b)
Invasive Breast Carcinoma (Code-1)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
CL Item
Tumor Invasion kann nicht beurteilt werden (B5c)
Tumor invasion cannot be assessed (finding) (Code-1)
C1276687 (UMLS CUI-1)
370048007 (SNOMED CT-1)
CL Item
anderer Tumor (B5d)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Malignant Neoplasms (Code-2)
C0006826 (UMLS CUI-2)
363346000 (SNOMED CT-2)
10028997 (MedDRA-2)
MTHU010328 (LOINC-2)
C00-C96 (ICD-10-CM-2)
Item
nicht_kodiert
integer
Korrelation
Code List
nicht_kodiert
CL Item
nicht_kodiert (K1 (sicher))
CL Item
nicht_kodiert (K2 (sicher))
CL Item
nicht_kodiert (K3a (unsicher, aber wahrscheinlich))
CL Item
nicht_kodiert (K3b (unsicher und wahrscheinlich))
Item Group
Aktion
Wiederholung MIB
Item
Wiederholung der Biopsie
boolean
Repeat (Code-1)
C0205341 (UMLS CUI-1)
27582007 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
reguläre weitere Vorsorge
Item
regülare Vorsorge
boolean
Screening procedure (Code-1)
C0220908 (UMLS CUI-1)
275926002 (SNOMED CT-1)
Regular (Code-2)
C0449581 (UMLS CUI-2)
17854005 (SNOMED CT-2)
Kontrolle in X Monaten
Item
geplante Kontrolle
boolean
checkup examination (Code-1)
C0598836 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
_ Monate
Item
Monate Check-Up
integer
month (qualifier value) (Code-1)
C0439231 (UMLS CUI-1)
258706009 (SNOMED CT-1)
MO (HL7 V3-1)
Kontrolle MG
Item
Check-Up Mammographie
boolean
Mammography (Code-1)
C0024671 (UMLS CUI-1)
71651007 (SNOMED CT-1)
10026735 (MedDRA-1)
checkup examination (Code-2)
C0598836 (UMLS CUI-2)
Konrolle Sono
Item
Check-Up Sonographie
boolean
Ultrasonography, Mammary (Code-1)
C0080264 (UMLS CUI-1)
47079000 (SNOMED CT-1)
checkup examination (Code-2)
C0598836 (UMLS CUI-2)
Konrolle MRT
Item
Check-Up MRT
boolean
Magnetic resonance imaging of breast (procedure) (Code-1)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
checkup examination (Code-2)
C0598836 (UMLS CUI-2)
weiterführende MIB
Item
zusätzliche Biopsie
boolean
Additional (Code-1)
C1524062 (UMLS CUI-1)
MTHU013802 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
diagnotische Excision
Item
Excisionsbiopsie
boolean
Excisional Biopsy (Code-1)
C0184921 (UMLS CUI-1)
8889005 (SNOMED CT-1)
onkologische OP
Item
onkologische Operation
boolean
Surgical Oncology (Code-1)
C1515090 (UMLS CUI-1)
Audit
Item
Audit
boolean
Audit (Code-1)
C1704775 (UMLS CUI-1)
Item Group
Tumorboardentscheidungen
Operation
Item
Operation
boolean
Operative Surgical Procedures (Code-1)
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)
Item
Intention
integer
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Therapieziel
Code List
Intention
CL Item
Adjuvant (adjuvant)
Adjuvant - intent (qualifier value) (Code-1)
C1298675 (UMLS CUI-1)
373846009 (SNOMED CT-1)
CL Item
Kurativ (kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Neoadjuvant (neoadjuvant)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
CL Item
Palliativ (palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
sonstiges (sonstiges)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Chemotherapie
Item
Chemotherapie
boolean
Chemotherapy Regimen (Code-1)
C0392920 (UMLS CUI-1)
69960004 (SNOMED CT-1)
10061758 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Item
Intention
integer
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)
Therapieziel
Code List
Intention
CL Item
Adjuvant (adjuvant)
Adjuvant - intent (qualifier value) (Code-1)
C1298675 (UMLS CUI-1)
373846009 (SNOMED CT-1)
CL Item
Kurativ (kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Neoadjuvant (neoadjuvant)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
CL Item
Palliativ (palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
sonstiges (sonstiges)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Strahlentherapie
Item
Bestrahlung
boolean
Therapeutic radiology procedure (Code-1)
C1522449 (UMLS CUI-1)
108290001 (SNOMED CT-1)
10037794 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Item
Intention
integer
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Therapeutic radiology procedure (Code-2)
C1522449 (UMLS CUI-2)
108290001 (SNOMED CT-2)
10037794 (MedDRA-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Therapieziel
Code List
Intention
CL Item
Adjuvant (adjuvant)
Adjuvant - intent (qualifier value) (Code-1)
C1298675 (UMLS CUI-1)
373846009 (SNOMED CT-1)
CL Item
Kurativ (kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Neoadjuvant (neoadjuvant)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
CL Item
Palliativ (palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
sonstiges (sonstiges)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Hormontherapie
Item
Hormon- / endokrine Therapie
boolean
Endocrine Therapy (Code-1)
C0279025 (UMLS CUI-1)
169413002 (SNOMED CT-1)
10065646 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Item
Intention
integer
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Endocrine Therapy (Code-2)
C0279025 (UMLS CUI-2)
169413002 (SNOMED CT-2)
10065646 (MedDRA-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Therapieziel
Code List
Intention
CL Item
Adjuvant (adjuvant)
Adjuvant - intent (qualifier value) (Code-1)
C1298675 (UMLS CUI-1)
373846009 (SNOMED CT-1)
CL Item
Kurativ (kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Neoadjuvant (neoadjuvant)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
CL Item
Palliativ (palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
sonstiges (sonstiges)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Immuntherapie
Item
Immuntherapie
boolean
Immunotherapy (Code-1)
C0021083 (UMLS CUI-1)
76334006 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Item
Intention
integer
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Immunotherapy (Code-2)
C0021083 (UMLS CUI-2)
76334006 (SNOMED CT-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Therapieziel
Code List
Intention
CL Item
Adjuvant (adjuvant)
Adjuvant - intent (qualifier value) (Code-1)
C1298675 (UMLS CUI-1)
373846009 (SNOMED CT-1)
CL Item
Kurativ (kurativ)
Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)
CL Item
Neoadjuvant (neoadjuvant)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
CL Item
Palliativ (palliativ)
Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)
CL Item
sonstiges (sonstiges)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Studienprotokoll
Item
Studienprotokoll
boolean
C2348563 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Studienprotokoll
Item
Studienprotokoll - Freitext
string
C2348563 (UMLS CUI-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Verlaufskontrolle
Item
Verlaufskontrolle
boolean
C1522577 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Verlaufskontrolle
Item
Verlaufskontrolle - Freitext
string
C1522577 (UMLS CUI-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Analgetika
Item
Analgetika
boolean
Pain management (Code-1)
C0002766 (UMLS CUI-1)
278414003 (SNOMED CT-1)
10056350 (MedDRA-1)
MTHU031888 (LOINC-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Analgetika
Item
Analgetika - Freitext
string
Pain management (Code-1)
C0002766 (UMLS CUI-1)
278414003 (SNOMED CT-1)
10056350 (MedDRA-1)
MTHU031888 (LOINC-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
sonstige
Item
andere Empfehlung
boolean
Advising (Code-1)
C1828381 (UMLS CUI-1)
424900004 (SNOMED CT-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
sonstige
Item
andere Empfehlung - Freitext
string
Advising (Code-1)
C1828381 (UMLS CUI-1)
424900004 (SNOMED CT-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
Re-Biopsie
Item
Re-Biopsie
boolean
Repeat (Code-1)
C0205341 (UMLS CUI-1)
27582007 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Bisphosphonate
Item
Bisphosphonate
boolean
Diphosphonates (Code-1)
C0012544 (UMLS CUI-1)
372907000 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Bisphosphonate
Item
Bisphosphonate - Freitext
string
Diphosphonates (Code-1)
C0012544 (UMLS CUI-1)
372907000 (SNOMED CT-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Radioiodtherapie
Item
Radioiodtherapie
boolean
Iodine 131 therapy (procedure) (Code-1)
C0454105 (UMLS CUI-1)
228698009 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Wiedervorstellung nach weiterer Diagnostik
Item
Wiedervorstellung nach Diagnostik
boolean
Follow-up visit (procedure) (Code-1)
C0589121 (UMLS CUI-1)
185389009 (SNOMED CT-1)
Post (Code-2)
C0231290 (UMLS CUI-2)
237679004 (SNOMED CT-2)
diagnostic procedure (Code-3)
C0430022 (UMLS CUI-3)
103693007 (SNOMED CT-3)
10061816 (MedDRA-3)
Act. Surveillance
Item
Active Surveillance
boolean
Active surveillance (regime/therapy) (Code-1)
C1827061 (UMLS CUI-1)
424313000 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
weitere Diagnostik
Item
Diagnostik notwendig
string
diagnostic procedure (Code-1)
C0430022 (UMLS CUI-1)
103693007 (SNOMED CT-1)
10061816 (MedDRA-1)
Need (Code-2)
C0027552 (UMLS CUI-2)
410525008 (SNOMED CT-2)
Therapie Freitext
Item
Therapie Freitext
string
Therapeutic procedure (Code-1)
C0087111 (UMLS CUI-1)
277132007 (SNOMED CT-1)
10053757 (MedDRA-1)
MTHU008880 (LOINC-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Datum
Item
Datum der Arzt-Unterschrift
date
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
112247003 (SNOMED CT-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Unterschrift Arzt
Item
Arzt-Unterschrift
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
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