Informationen:
Fehler:
ID
4085
Beschreibung
HIS form ORBIS. with friendly permission form gynecology (Dr. Tio) and medical informatics department (Dr. Breil)
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 surgery planning breast cancer
Ähnliche Modelle
HIS
- StudyEvent: HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Datum
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)
Item
Side
integer
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Tumor site (Code-2)
C0475445 (UMLS CUI-2)
263591006 (SNOMED CT-2)
MTHU015562 (LOINC-2)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Tumor site (Code-2)
C0475445 (UMLS CUI-2)
263591006 (SNOMED CT-2)
MTHU015562 (LOINC-2)
CL Item
Right (links)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
24028007 (SNOMED CT-1)
CL Item
Left (rechts)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
7771000 (SNOMED CT-1)
CL Item
Bilateral (beidseits)
C0238767 (UMLS CUI-1)
51440002 (SNOMED CT-1)
51440002 (SNOMED CT-1)
Item
Histopathology
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)
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)
CL Item
B3 (B3)
Neoplasm, Uncertain Whether Benign or Malignant (Code-1)
C0677041 (UMLS CUI-1)
86251006 (SNOMED CT-1)
C0677041 (UMLS CUI-1)
86251006 (SNOMED CT-1)
CL Item
benign (benigne)
Benign (Code-1)
C0205183 (UMLS CUI-1)
30807003 (SNOMED CT-1)
C0205183 (UMLS CUI-1)
30807003 (SNOMED CT-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
Invasive Carcinoma (invasiv)
Invasive Breast Carcinoma (Code-1)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
CL Item
Invasive Lobular Breast Carcinoma (IL)
merged_coding (Code-Info)
Invasive Lobular Breast Carcinoma (Code-1)
CL029510 (UMLS CUI-1)
Invasive Lobular Breast Carcinoma (Code-1)
CL029510 (UMLS CUI-1)
CL Item
Not Otherwise Specified (NOS)
merged_coding (Code-Info)
Not Otherwise Specified (Code-1)
C1518425 (UMLS CUI-1)
Not Otherwise Specified (Code-1)
C1518425 (UMLS CUI-1)
Item
Histologic Grade
integer
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
371469007 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
CL Item
G1 grade (1)
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 (2)
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 (3)
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)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
C1273709 (UMLS CUI-1)
384736003 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
CL Item
Low Grade (1)
Low Grade (Code-1)
C1282907 (UMLS CUI-1)
C1282907 (UMLS CUI-1)
CL Item
Intermediate Grade (2)
Intermediate Grade (Code-1)
C1512863 (UMLS CUI-1)
C1512863 (UMLS CUI-1)
CL Item
High Grade (3)
High Grade (Code-1)
CL378245 (UMLS CUI-1)
CL378245 (UMLS CUI-1)
Durchm. Herd (mm)
Item
diameter of lesion
integer
Diameter (qualifier value) (Code-1)
C1301886 (UMLS CUI-1)
81827009 (SNOMED CT-1)
MTHU002654 (LOINC-1)
Lesion (Code-2)
C0221198 (UMLS CUI-2)
49755003 (SNOMED CT-2)
C1301886 (UMLS CUI-1)
81827009 (SNOMED CT-1)
MTHU002654 (LOINC-1)
Lesion (Code-2)
C0221198 (UMLS CUI-2)
49755003 (SNOMED CT-2)
MR-Befund
Item
Magnetic Resonance Imaging
boolean
Magnetic resonance imaging of breast (procedure) (Code-1)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
MR-Befund
Item
MRI finding
string
Magnetic resonance imaging of breast (procedure) (Code-1)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
Finding (Code-2)
C1285578 (UMLS CUI-2)
363787002 (SNOMED CT-2)
C0344104 (UMLS CUI-1)
241615005 (SNOMED CT-1)
Finding (Code-2)
C1285578 (UMLS CUI-2)
363787002 (SNOMED CT-2)
zus HB
Item
additional Lesion
boolean
Lesion (Code-1)
C0221198 (UMLS CUI-1)
49755003 (SNOMED CT-1)
Additional (Code-2)
C1524062 (UMLS CUI-2)
MTHU013802 (LOINC-2)
C0221198 (UMLS CUI-1)
49755003 (SNOMED CT-1)
Additional (Code-2)
C1524062 (UMLS CUI-2)
MTHU013802 (LOINC-2)
zus HB
Item
additional Lesion - free text
string
Lesion (Code-1)
C0221198 (UMLS CUI-1)
49755003 (SNOMED CT-1)
Additional (Code-2)
C1524062 (UMLS CUI-2)
MTHU013802 (LOINC-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
C0221198 (UMLS CUI-1)
49755003 (SNOMED CT-1)
Additional (Code-2)
C1524062 (UMLS CUI-2)
MTHU013802 (LOINC-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
Durchm. AST (mm)
Item
Diameter abnormal structure
integer
Diameter (Code-1)
C1301886 (UMLS CUI-1)
81827009 (SNOMED CT-1)
MTHU002654 (LOINC-1)
Abnormal (Code-2)
C0205161 (UMLS CUI-2)
263654008 (SNOMED CT-2)
Structure (Code-3)
C0678594 (UMLS CUI-3)
C1301886 (UMLS CUI-1)
81827009 (SNOMED CT-1)
MTHU002654 (LOINC-1)
Abnormal (Code-2)
C0205161 (UMLS CUI-2)
263654008 (SNOMED CT-2)
Structure (Code-3)
C0678594 (UMLS CUI-3)
Durchm. MK (mm)
Item
Diameter Microcalcification
integer
Microcalcification (Code-1)
C0521174 (UMLS CUI-1)
12747003 (SNOMED CT-1)
MTHU020083 (LOINC-1)
Diameter (qualifier value) (Code-2)
C1301886 (UMLS CUI-2)
81827009 (SNOMED CT-2)
MTHU002654 (LOINC-2)
C0521174 (UMLS CUI-1)
12747003 (SNOMED CT-1)
MTHU020083 (LOINC-1)
Diameter (qualifier value) (Code-2)
C1301886 (UMLS CUI-2)
81827009 (SNOMED CT-2)
MTHU002654 (LOINC-2)
Item
Breast size
integer
Breast size (observable entity) (Code-1)
C0425782 (UMLS CUI-1)
248808008 (SNOMED CT-1)
C0425782 (UMLS CUI-1)
248808008 (SNOMED CT-1)
CL Item
not_coded (A)
CL Item
not_coded (B)
CL Item
not_coded (C)
CL Item
not_coded (D)
CL Item
not_coded (2D)
ME
Item
Mastectomy
boolean
Mastectomy (Code-1)
C0024881 (UMLS CUI-1)
10026878 (MedDRA-1)
85.4 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0024881 (UMLS CUI-1)
10026878 (MedDRA-1)
85.4 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
BET
Item
Breast Conservation Treatment
boolean
Breast Conservation Treatment (Code-1)
C0917927 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0917927 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
onkopl. BET
Item
reconstructive breast conservation treatment
boolean
Plastic Surgical Procedures (Code-1)
C0677616 (UMLS CUI-1)
286553006 (SNOMED CT-1)
10062082 (MedDRA-1)
Breast Conservation Treatment (Code-2)
C0917927 (UMLS CUI-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
C0677616 (UMLS CUI-1)
286553006 (SNOMED CT-1)
10062082 (MedDRA-1)
Breast Conservation Treatment (Code-2)
C0917927 (UMLS CUI-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
DE
Item
Excisional Biopsy
boolean
Excisional Biopsy (Code-1)
C0184921 (UMLS CUI-1)
8889005 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0184921 (UMLS CUI-1)
8889005 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
NR
Item
Repeated Surgical Procedure
boolean
Repeated Surgical Procedure (Code-1)
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
sek ME
Item
secondary mastectomy
boolean
Mastectomy (Code-1)
C0024881 (UMLS CUI-1)
10026878 (MedDRA-1)
85.4 (ICD-9-CM-1)
Secondary (Code-2)
C0175668 (UMLS CUI-2)
2603003 (SNOMED CT-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
C0024881 (UMLS CUI-1)
10026878 (MedDRA-1)
85.4 (ICD-9-CM-1)
Secondary (Code-2)
C0175668 (UMLS CUI-2)
2603003 (SNOMED CT-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Maße Segment (mm)
Item
size of segment
integer
Anatomical segmentation (Code-1)
C0441635 (UMLS CUI-1)
264193005 (SNOMED CT-1)
size (Code-2)
C0456389 (UMLS CUI-2)
246115007 (SNOMED CT-2)
MTHU010347 (LOINC-2)
C0441635 (UMLS CUI-1)
264193005 (SNOMED CT-1)
size (Code-2)
C0456389 (UMLS CUI-2)
246115007 (SNOMED CT-2)
MTHU010347 (LOINC-2)
Item
pre-biopsy localization using wire
integer
for_compare (Code-Info)
Pre-biopsy localization of breast lesion using self retaining wire (procedure) (Code-1)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
Pre-biopsy localization of breast lesion using self retaining wire (procedure) (Code-1)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
Code List
pre-biopsy localization using wire
CL Item
Sonography guided wire localization (sonograf. Markierung)
changed_datatype (Code-Info)
Insertion of guide wire into breast using ultrasound guidance (procedure) (Code-1)
C2315526 (UMLS CUI-1)
433222002 (SNOMED CT-1)
Insertion of guide wire into breast using ultrasound guidance (procedure) (Code-1)
C2315526 (UMLS CUI-1)
433222002 (SNOMED CT-1)
CL Item
Plain X-ray guided wire localization (stereotakt Markierung)
changed_datatype (Code-Info)
Plain X-ray guided wire localization of breast lesion (procedure) (Code-1)
C1997063 (UMLS CUI-1)
428907005 (SNOMED CT-1)
Plain X-ray guided wire localization of breast lesion (procedure) (Code-1)
C1997063 (UMLS CUI-1)
428907005 (SNOMED CT-1)
Anzahl Markierungen
Item
count of localization with wire
integer
Pre-biopsy localization of breast lesion using self retaining wire (procedure) (Code-1)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
Count of entities (property) (qualifier value) (Code-2)
C0449788 (UMLS CUI-2)
410681005 (SNOMED CT-2)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
Count of entities (property) (qualifier value) (Code-2)
C0449788 (UMLS CUI-2)
410681005 (SNOMED CT-2)
Besonderheiten Markierungen
Item
comment guided wire
string
Pre-biopsy localization of breast lesion using self retaining wire (procedure) (Code-1)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
Präparate Radiographie
Item
intraoperative mammography of specimen
boolean
Specimen mammography (procedure) (Code-1)
C0203031 (UMLS CUI-1)
80865008 (SNOMED CT-1)
Intraoperative (Code-2)
C0456904 (UMLS CUI-2)
277671009 (SNOMED CT-2)
C0203031 (UMLS CUI-1)
80865008 (SNOMED CT-1)
Intraoperative (Code-2)
C0456904 (UMLS CUI-2)
277671009 (SNOMED CT-2)
Makro
Item
intraoperative macroscopic examination
boolean
Sample macroscopy (procedure) (Code-1)
C0430385 (UMLS CUI-1)
168126000 (SNOMED CT-1)
Intraoperative (Code-2)
C0456904 (UMLS CUI-2)
277671009 (SNOMED CT-2)
C0430385 (UMLS CUI-1)
168126000 (SNOMED CT-1)
Intraoperative (Code-2)
C0456904 (UMLS CUI-2)
277671009 (SNOMED CT-2)
Scheiben Radiographie
Item
X-ray of pathological specimen
boolean
X-ray of pathological specimen (procedure) (Code-1)
C0412004 (UMLS CUI-1)
169116004 (SNOMED CT-1)
C0412004 (UMLS CUI-1)
169116004 (SNOMED CT-1)
SLNB
Item
Sentinel Lymph Node Biopsy
boolean
Sentinel Lymph Node Biopsy (Code-1)
C0796693 (UMLS CUI-1)
396487001 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0796693 (UMLS CUI-1)
396487001 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
ALND
Item
Axillary Lymph Node Dissection
boolean
Axillary Lymph Node Dissection (Code-1)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
IORT
Item
Intraoperative Radiation Therapy
boolean
Intraoperative Radiation Therapy) (Code-1)
C0338240 (UMLS CUI-1)
10065519 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0338240 (UMLS CUI-1)
10065519 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Studien
Item
Clinical Trials
string
C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)
110465008 (SNOMED CT-1)
Besonderheiten
Item
free text
string
Free Text Format (Code-1)
C2348713 (UMLS CUI-1)
C2348713 (UMLS CUI-1)
Verantwortlicher Arzt
Item
responsible physician
string
Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)