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Fehler:
ID
4081
Beschreibung
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
Stichworte
Versionen (1)
- 07.08.13 07.08.13 -
Hochgeladen am
7. August 2013
DOI
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Lizenz
Creative Commons BY-NC 3.0 Legacy
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HIS cancer conference after surgery breast cancer
Ähnliche Modelle
HIS
- StudyEvent: HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Aufnahmedatum
Item
Aufnahmedatum
date
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)
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)
184100006 (SNOMED CT-1)
Nachname
Item
Patienten-Nachname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patienten-Vorname
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
184095009 (SNOMED CT-1)
Geburtsdatum
Item
Patienten-Geburtsdatum
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-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)
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)
C0809949 (UMLS CUI-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
PHYS (HL7 V3-2)
vom
Item
Datum der Konferenz
date
Item
Histologischer Typ
integer
Histologic Type (Code-1)
C0449574 (UMLS CUI-1)
263541007 (SNOMED CT-1)
MTHU020048 (LOINC-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
C0449574 (UMLS CUI-1)
263541007 (SNOMED CT-1)
MTHU020048 (LOINC-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
CL Item
nicht anders spezifiziert (NOS)
Not Otherwise Specified (Code-1)
C1518425 (UMLS CUI-1)
C1518425 (UMLS CUI-1)
CL Item
invasives lobuläre Karzinom (IL)
Invasive Lobular Breast Carcinoma (Code-1)
CL029510 (UMLS CUI-1)
CL029510 (UMLS CUI-1)
CL Item
DCIS (DCIS)
Noninfiltrating Intraductal Carcinoma (Code-1)
C0007124 (UMLS CUI-1)
86616005 (SNOMED CT-1)
10013806 (MedDRA-1)
D05.1 (ICD-10-CM-1)
C0007124 (UMLS CUI-1)
86616005 (SNOMED CT-1)
10013806 (MedDRA-1)
D05.1 (ICD-10-CM-1)
CL Item
lobuläres Carcinoma in situ (CLIS ext. Type)
Lobular carcinoma in situ of breast (Code-1)
C0279563 (UMLS CUI-1)
109888004 (SNOMED CT-1)
10024744 (MedDRA-1)
D05.0 (ICD-10-CM-1)
C0279563 (UMLS CUI-1)
109888004 (SNOMED CT-1)
10024744 (MedDRA-1)
D05.0 (ICD-10-CM-1)
CL Item
andere histologischer Typ (sonstige)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
sonstige Histologie
Item
sonstige Histologie
string
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Histologic Type (Code-2)
C0449574 (UMLS CUI-2)
263541007 (SNOMED CT-2)
MTHU020048 (LOINC-2)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Histologic Type (Code-2)
C0449574 (UMLS CUI-2)
263541007 (SNOMED CT-2)
MTHU020048 (LOINC-2)
Tumorgröße
Item
Tumorgröße
integer
mm (Item-Info)
Tumor size (observable entity) (Code-1)
C0475440 (UMLS CUI-1)
263605001 (SNOMED CT-1)
Tumor size (observable entity) (Code-1)
C0475440 (UMLS CUI-1)
263605001 (SNOMED CT-1)
DCIS Größe
Item
DCIS Größe
integer
mm (Item-Info)
size (Code-1)
C0456389 (UMLS CUI-1)
246115007 (SNOMED CT-1)
MTHU010347 (LOINC-1)
Noninfiltrating Intraductal Carcinoma (Code-2)
C0007124 (UMLS CUI-2)
86616005 (SNOMED CT-2)
10013806 (MedDRA-2)
D05.1 (ICD-10-CM-2)
size (Code-1)
C0456389 (UMLS CUI-1)
246115007 (SNOMED CT-1)
MTHU010347 (LOINC-1)
Noninfiltrating Intraductal Carcinoma (Code-2)
C0007124 (UMLS CUI-2)
86616005 (SNOMED CT-2)
10013806 (MedDRA-2)
D05.1 (ICD-10-CM-2)
Item
Histologisches Grading
integer
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
371469007 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
CL Item
G1 (G1)
G1 grade (finding) (Code-1)
C0475269 (UMLS CUI-1)
54102005 (SNOMED CT-1)
C0475269 (UMLS CUI-1)
54102005 (SNOMED CT-1)
CL Item
G2 (G2)
G2 grade (finding) (Code-1)
C0475270 (UMLS CUI-1)
1663004 (SNOMED CT-1)
C0475270 (UMLS CUI-1)
1663004 (SNOMED CT-1)
CL Item
G3 (G3)
G3 grade (finding) (Code-1)
C0475271 (UMLS CUI-1)
61026006 (SNOMED CT-1)
C0475271 (UMLS CUI-1)
61026006 (SNOMED CT-1)
Item
Kernmalignitätsgrad
integer
Nuclear grade finding (finding) (Code-1)
C1273709 (UMLS CUI-1)
384736003 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
C1273709 (UMLS CUI-1)
384736003 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
CL Item
low (low)
Low Grade (Code-1)
C1282907 (UMLS CUI-1)
C1282907 (UMLS CUI-1)
CL Item
intermediate (intermediate)
Intermediate Grade (Code-1)
C1512863 (UMLS CUI-1)
C1512863 (UMLS CUI-1)
CL Item
high (high)
High Grade (Code-1)
CL378245 (UMLS CUI-1)
CL378245 (UMLS CUI-1)
Item
Östrogen-Rezeptor
integer
Status of estrogen receptors of neoplasm (observable entity) (Code-1)
C2919271 (UMLS CUI-1)
445028008 (SNOMED CT-1)
C2919271 (UMLS CUI-1)
445028008 (SNOMED CT-1)
CL Item
negativ (negativ)
Estrogen receptor negative neoplasm (disorder) (Code-1)
C2584629 (UMLS CUI-1)
441117001 (SNOMED CT-1)
C2584629 (UMLS CUI-1)
441117001 (SNOMED CT-1)
CL Item
positiv (positiv)
Estrogen receptor positive tumor (disorder) (Code-1)
C1562312 (UMLS CUI-1)
416053008 (SNOMED CT-1)
C1562312 (UMLS CUI-1)
416053008 (SNOMED CT-1)
% positiv
Item
% positiv
integer
Percentage unit (qualifier value) (Code-1)
C1532336 (UMLS CUI-1)
415067009 (SNOMED CT-1)
Estrogen receptor positive tumor (disorder) (Code-2)
C1562312 (UMLS CUI-2)
416053008 (SNOMED CT-2)
C1532336 (UMLS CUI-1)
415067009 (SNOMED CT-1)
Estrogen receptor positive tumor (disorder) (Code-2)
C1562312 (UMLS CUI-2)
416053008 (SNOMED CT-2)
Item
Progesteron-Rezeptor
integer
Status of progesterone receptors of neoplasm (observable entity) (Code-1)
C2919590 (UMLS CUI-1)
445029000 (SNOMED CT-1)
C2919590 (UMLS CUI-1)
445029000 (SNOMED CT-1)
CL Item
negativ (negativ)
Progesterone receptor negative neoplasm (disorder) (Code-1)
C2584628 (UMLS CUI-1)
441118006 (SNOMED CT-1)
C2584628 (UMLS CUI-1)
441118006 (SNOMED CT-1)
CL Item
positiv (positiv)
Progesterone receptor positive tumor (disorder) (Code-1)
C1562928 (UMLS CUI-1)
416561008 (SNOMED CT-1)
C1562928 (UMLS CUI-1)
416561008 (SNOMED CT-1)
% positiv
Item
% positiv
integer
Percentage unit (qualifier value) (Code-1)
C1532336 (UMLS CUI-1)
415067009 (SNOMED CT-1)
Progesterone receptor positive tumor (disorder) (Code-2)
C1562928 (UMLS CUI-2)
416561008 (SNOMED CT-2)
C1532336 (UMLS CUI-1)
415067009 (SNOMED CT-1)
Progesterone receptor positive tumor (disorder) (Code-2)
C1562928 (UMLS CUI-2)
416561008 (SNOMED CT-2)
CL Item
negativ (0)
HER2-negative breast cancer (Code-1)
CL412283 (UMLS CUI-1)
CL412283 (UMLS CUI-1)
CL Item
negativ (1+)
HER2-negative breast cancer (Code-1)
CL412283 (UMLS CUI-1)
CL412283 (UMLS CUI-1)
CL Item
Borderline (2+)
Borderline (Code-1)
C0205189 (UMLS CUI-1)
C0205189 (UMLS CUI-1)
CL Item
positiv (3+)
HER2-positive carcinoma of breast (disorder) (Code-1)
C1960398 (UMLS CUI-1)
427685000 (SNOMED CT-1)
C1960398 (UMLS CUI-1)
427685000 (SNOMED CT-1)
Item
Fluoreszenz-in-situ-Hybridisierung
integer
Fluorescent in Situ Hybridization (Code-1)
C0162789 (UMLS CUI-1)
426329006 (SNOMED CT-1)
10066931 (MedDRA-1)
C0162789 (UMLS CUI-1)
426329006 (SNOMED CT-1)
10066931 (MedDRA-1)
CL Item
negativ (neg.)
Negative Finding (Code-1)
C0205160 (UMLS CUI-1)
260385009 (SNOMED CT-1)
C0205160 (UMLS CUI-1)
260385009 (SNOMED CT-1)
CL Item
positiv (pos.)
Positive Finding (Code-1)
C1446409 (UMLS CUI-1)
10828004 (SNOMED CT-1)
C1446409 (UMLS CUI-1)
10828004 (SNOMED CT-1)
CL Item
mamillär (mamillär)
Nippled (qualifier value) (Code-1)
C0457424 (UMLS CUI-1)
278274006 (SNOMED CT-1)
C0457424 (UMLS CUI-1)
278274006 (SNOMED CT-1)
CL Item
peripher (peripher)
Peripheral (Code-1)
C0205100 (UMLS CUI-1)
14414005 (SNOMED CT-1)
C0205100 (UMLS CUI-1)
14414005 (SNOMED CT-1)
CL Item
ventral (ventral)
Ventral (Code-1)
C1704448 (UMLS CUI-1)
255549009 (SNOMED CT-1)
C1704448 (UMLS CUI-1)
255549009 (SNOMED CT-1)
CL Item
dorsal (dorsal)
Dorsal (Code-1)
C0205095 (UMLS CUI-1)
255554000 (SNOMED CT-1)
C0205095 (UMLS CUI-1)
255554000 (SNOMED CT-1)
CL Item
cranial (cranial)
Cephalad (Code-1)
C0205096 (UMLS CUI-1)
66787007 (SNOMED CT-1)
C0205096 (UMLS CUI-1)
66787007 (SNOMED CT-1)
CL Item
caudal (caudal)
Caudal (Code-1)
C0205097 (UMLS CUI-1)
3583002 (SNOMED CT-1)
C0205097 (UMLS CUI-1)
3583002 (SNOMED CT-1)
CL Item
lateral (lateral)
Lateral (Code-1)
C0205093 (UMLS CUI-1)
49370004 (SNOMED CT-1)
C0205093 (UMLS CUI-1)
49370004 (SNOMED CT-1)
CL Item
medial (medial)
Medial (Code-1)
C0205098 (UMLS CUI-1)
255561001 (SNOMED CT-1)
C0205098 (UMLS CUI-1)
255561001 (SNOMED CT-1)
invasiv
Item
Sicherheitsabstand invasives Karzinom
string
Invasive Breast Carcinoma (Code-1)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
margin of safety (Code-2)
C0243168 (UMLS CUI-2)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
margin of safety (Code-2)
C0243168 (UMLS CUI-2)
DCIS
Item
Sicherheitsabstand DCIS
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)
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)
NR notwendig
Item
Revisionsoperation
boolean
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
Anzahl
Item
Anzahl der untersuchten Sentinellymphknoten
integer
C2733493 (UMLS CUI-1)
444411008 (SNOMED CT-1)
444411008 (SNOMED CT-1)
Item
Befund Sentinel Lymphknoten
integer
Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Sentinel Lymph Node (Code-2)
C0677944 (UMLS CUI-2)
330469005 (SNOMED CT-2)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Sentinel Lymph Node (Code-2)
C0677944 (UMLS CUI-2)
330469005 (SNOMED CT-2)
CL Item
kein Tumor (tumorfrei)
No neoplasm (qualifier value) (Code-1)
C0445120 (UMLS CUI-1)
264869003 (SNOMED CT-1)
C0445120 (UMLS CUI-1)
264869003 (SNOMED CT-1)
CL Item
Mikrometastasen (Micrometastasen)
Micrometastasis (Code-1)
C1513276 (UMLS CUI-1)
C1513276 (UMLS CUI-1)
CL Item
Makrometastasen (Makrometastasen)
Metastasis (Code-1)
C0027627 (UMLS CUI-1)
C0027627 (UMLS CUI-1)
CL Item
intraoperativ (intraoperativ festgestellt)
Intraoperative (Code-1)
C0456904 (UMLS CUI-1)
277671009 (SNOMED CT-1)
C0456904 (UMLS CUI-1)
277671009 (SNOMED CT-1)
CL Item
histologisch (erst in endgültiger Histologie festgestellt)
Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Axilladissektion
Item
Axilladissektion
boolean
for_compare (Code-Info)
Axillary Lymph Node Dissection (Code-1)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Axillary Lymph Node Dissection (Code-1)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Anzahl
Item
Anzahl der untersuchten Lymphknoten
integer
C2733494 (UMLS CUI-1)
444025001 (SNOMED CT-1)
444025001 (SNOMED CT-1)
davon befallen
Item
Anzahl der befallenen Lymphknoten
integer
Number of lymph nodes involved by malignant neoplasm (observable entity) (Code-1)
C2732750 (UMLS CUI-1)
443527007 (SNOMED CT-1)
C2732750 (UMLS CUI-1)
443527007 (SNOMED CT-1)
vom
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)
C0804663 (UMLS CUI-1)
21875-0 (LOINC-1)
operative Therapie abgeschlossen
Item
Operation
boolean
sek. LNE
Item
sekundäre Lymphknotenentfernung
boolean
Excision of regional lymph nodes (procedure) (Code-1)
C0337383 (UMLS CUI-1)
21525004 (SNOMED CT-1)
Secondary (Code-2)
C0175668 (UMLS CUI-2)
2603003 (SNOMED CT-2)
C0337383 (UMLS CUI-1)
21525004 (SNOMED CT-1)
Secondary (Code-2)
C0175668 (UMLS CUI-2)
2603003 (SNOMED CT-2)
Nachresektion
Item
Revisionsoperation
boolean
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
sek. ME
Item
sekundär totale Mastektomie
boolean
Simple mastectomy (Code-1)
C0024886 (UMLS CUI-1)
172043006 (SNOMED CT-1)
10040700 (MedDRA-1)
85.41 (ICD-9-CM-1)
Secondary (Code-2)
C0175668 (UMLS CUI-2)
2603003 (SNOMED CT-2)
C0024886 (UMLS CUI-1)
172043006 (SNOMED CT-1)
10040700 (MedDRA-1)
85.41 (ICD-9-CM-1)
Secondary (Code-2)
C0175668 (UMLS CUI-2)
2603003 (SNOMED CT-2)
pT
Item
pT Stadium
string
pT category finding (finding) (Code-1)
C1272834 (UMLS CUI-1)
385385001 (SNOMED CT-1)
C1272834 (UMLS CUI-1)
385385001 (SNOMED CT-1)
pN
Item
pN Stadium
string
pN category finding (finding) (Code-1)
C1272833 (UMLS CUI-1)
385381005 (SNOMED CT-1)
C1272833 (UMLS CUI-1)
385381005 (SNOMED CT-1)
L
Item
Lymphgefäßinvasion
string
Lymphatic (small vessel) tumor invasion finding (finding) (Code-1)
C1272791 (UMLS CUI-1)
385414009 (SNOMED CT-1)
C1272791 (UMLS CUI-1)
385414009 (SNOMED CT-1)
V
Item
Veneninvasion
string
C1710625 (UMLS CUI-1)
cM
Item
cM Stadium
string
cM category (observable entity) (Code-1)
C1275856 (UMLS CUI-1)
399387003 (SNOMED CT-1)
C1275856 (UMLS CUI-1)
399387003 (SNOMED CT-1)
G
Item
Histologisches Grading
integer
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
371469007 (SNOMED CT-1)
Unterschrift
Item
Unterschrift
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
C0807938 (UMLS CUI-1)