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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
Admission date
date
PatientenID
Item
Patient Identification Number
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
Patient sex
string
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
184100006 (SNOMED CT-1)
Nachname
Item
Patient surname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patient forename
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
184095009 (SNOMED CT-1)
Geburtsdatum
Item
Patient date of birth
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
184099003 (SNOMED CT-1)
Aufnahmezeit
Item
Admission hour
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
Physician admission
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
Date of cancer conference
date
Item
Histologic Type
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
Not Otherwise Specified (NOS)
Not Otherwise Specified (Code-1)
C1518425 (UMLS CUI-1)
C1518425 (UMLS CUI-1)
CL Item
Invasive Lobular Breast Carcinoma (IL)
Invasive Lobular Breast Carcinoma (Code-1)
CL029510 (UMLS CUI-1)
CL029510 (UMLS CUI-1)
CL Item
Noninfiltrating Intraductal Carcinoma (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
Lobular carcinoma in situ of breast (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
other histologic type (sonstige)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
sonstige Histologie
Item
other histopathology
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
Tumor size
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
size of non infiltrating intraductal carcinoma
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
Histologic Grade
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 grade (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 grade (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 grade (G3)
G3 grade (finding) (Code-1)
C0475271 (UMLS CUI-1)
61026006 (SNOMED CT-1)
C0475271 (UMLS CUI-1)
61026006 (SNOMED CT-1)
Item
nuclear grade
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 Grade (low)
Low Grade (Code-1)
C1282907 (UMLS CUI-1)
C1282907 (UMLS CUI-1)
CL Item
Intermediate Grade (intermediate)
Intermediate Grade (Code-1)
C1512863 (UMLS CUI-1)
C1512863 (UMLS CUI-1)
CL Item
High Grade (high)
High Grade (Code-1)
CL378245 (UMLS CUI-1)
CL378245 (UMLS CUI-1)
Item
Estrogen Receptor
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
negative (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
positive (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
percentage 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
progesterone receptor
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
negative (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
positive (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
percentage 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
negative (0)
HER2-negative breast cancer (Code-1)
CL412283 (UMLS CUI-1)
CL412283 (UMLS CUI-1)
CL Item
negative (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
positive (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
Fluorescent in Situ Hybridization
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
negative (neg.)
Negative Finding (Code-1)
C0205160 (UMLS CUI-1)
260385009 (SNOMED CT-1)
C0205160 (UMLS CUI-1)
260385009 (SNOMED CT-1)
CL Item
postive (pos.)
Positive Finding (Code-1)
C1446409 (UMLS CUI-1)
10828004 (SNOMED CT-1)
C1446409 (UMLS CUI-1)
10828004 (SNOMED CT-1)
CL Item
Nippled (mamillär)
Nippled (qualifier value) (Code-1)
C0457424 (UMLS CUI-1)
278274006 (SNOMED CT-1)
C0457424 (UMLS CUI-1)
278274006 (SNOMED CT-1)
CL Item
Peripheral (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
Cephalad (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
safety margin Invasive Carcinoma
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
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)
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
Repeated Surgical Procedure
boolean
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
Anzahl
Item
Number of sentinel lymph nodes examined
integer
C2733493 (UMLS CUI-1)
444411008 (SNOMED CT-1)
444411008 (SNOMED CT-1)
Item
finding sentinel lymph node
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
No neoplasm (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
Micrometastasis (Micrometastasen)
Micrometastasis (Code-1)
C1513276 (UMLS CUI-1)
C1513276 (UMLS CUI-1)
CL Item
Metastasis (Makrometastasen)
Metastasis (Code-1)
C0027627 (UMLS CUI-1)
C0027627 (UMLS CUI-1)
CL Item
Intraoperative (intraoperativ festgestellt)
Intraoperative (Code-1)
C0456904 (UMLS CUI-1)
277671009 (SNOMED CT-1)
C0456904 (UMLS CUI-1)
277671009 (SNOMED CT-1)
CL Item
Histopathology (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
Axillary Lymph Node Dissection
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
Number of lymph nodes examined
integer
C2733494 (UMLS CUI-1)
444025001 (SNOMED CT-1)
444025001 (SNOMED CT-1)
davon befallen
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)
C2732750 (UMLS CUI-1)
443527007 (SNOMED CT-1)
vom
Item
Date of cancer conference
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
Operative Surgical Procedures
boolean
sek. LNE
Item
secondary lymph node excision
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
Repeated Surgical Procedure
boolean
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
sek. ME
Item
secondary total mastectomy
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 stage
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 Stage
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
Lymph vessel invasion
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
Venous Invasion
string
C1710625 (UMLS CUI-1)
cM
Item
cM Stage
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
Histologic Grade
integer
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
371469007 (SNOMED CT-1)
Unterschrift
Item
Signature
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
C0807938 (UMLS CUI-1)