ID

4087

Description

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

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 Talk after conference breast cancer

German English

HIS

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

Patientenaufkleber groß

Admission date
Description

Aufnahmedatum

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Patient Identification Number
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
Patient sex
Description

Geschlecht

Data type

string

Alias
UMLS CUI-1
C0150831
SNOMED CT-1
184100006
Patient surname
Description

Nachname

Data type

string

Alias
UMLS CUI-1
C0421448
SNOMED CT-1
184096005
Patient forename
Description

Vorname

Data type

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patient date of birth
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Admission hour
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
Physician admission
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
Gespräch nach Tumorkonferenz
Description

Gespräch nach Tumorkonferenz

date
Description

Patientin informiert

Data type

date

Alias
Code-1
Visit Date
UMLS CUI-1
C1320303
SNOMED CT-1
406543005
responsible person
Description

durch Dr.

Data type

string

Alias
Code-1
Responsible Person
UMLS CUI-1
C1273518
SNOMED CT-1
394851003
Informed consent for decision cancer conference obtained
Description

mit Empfehlung einverstanden

Data type

boolean

Alias
Code-1
Informed consent obtained
UMLS CUI-1
C0514044
LOINC-1
MTHU008888
Code-2
Cancer conference
UMLS CUI-2
C0805438
LOINC-2
MTHU010336
Code-3
Decision
UMLS CUI-3
C0679006
change of cancer conference decision
Description

wenn nein, folgende Abweichungen

Data type

string

Alias
Code-1
Change
UMLS CUI-1
C0392747
SNOMED CT-1
243326001
Code-2
Decision
UMLS CUI-2
C0679006
Code-3
Cancer conference
UMLS CUI-3
C0805438
LOINC-3
MTHU010336
planned procedures
Description

weitere Maßnahmen wurden eingeleitet

Data type

integer

Alias
Code-1
Therapeutic procedure
UMLS CUI-1
C0087111
SNOMED CT-1
277132007
MedDRA-1
10053757
LOINC-1
MTHU008880
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Patient informed systemic therapy
Description

Aufklärung über Systemtherapie

Data type

boolean

Alias
Code-1
Informing patient (procedure)
UMLS CUI-1
C0588446
SNOMED CT-1
310866003
Code-2
Systemic Therapy
UMLS CUI-2
C1515119
Patient informed endocrin therapy
Description

Aufklärung über Systemtherapie: endokrine Therapie

Data type

boolean

Alias
Code-1
Informing patient (procedure)
UMLS CUI-1
C0588446
SNOMED CT-1
310866003
Code-2
Endocrine Therapy
UMLS CUI-2
C0279025
SNOMED CT-2
169413002
MedDRA-2
10065646
Patient informed chemotherapy
Description

Aufklärung über Systemtherapie: Chemotherapie

Data type

boolean

Alias
Code-1
Informing patient (procedure)
UMLS CUI-1
C0588446
SNOMED CT-1
310866003
Code-2
Chemotherapy Regimen
UMLS CUI-2
C0392920
SNOMED CT-2
69960004
MedDRA-2
10061758
Patient informed immunotherapy
Description

Aufklärung über Systemtherapie: Herceptin

Data type

boolean

Alias
Code-1
Informing patient (procedure)
UMLS CUI-1
C0588446
SNOMED CT-1
310866003
Code-2
Immunotherapy
UMLS CUI-2
C0021083
SNOMED CT-2
76334006
Prescriptions endocrine therapy
Description

Rp. Antihormonelle Therapie

Data type

boolean

Alias
Code-1
Drug Prescriptions
UMLS CUI-1
C0033081
SNOMED CT-1
182817000
LOINC-1
MTHU035094
Code-2
Endocrine Therapy
UMLS CUI-2
C0279025
SNOMED CT-2
169413002
MedDRA-2
10065646
Information endocrine therapy
Description

Infobogen endokrine Therapie ausgehändigt

Data type

boolean

Alias
Code-1
Information
UMLS CUI-1
CL414911
Code-2
Endocrine Therapy
UMLS CUI-2
C0279025
SNOMED CT-2
169413002
MedDRA-2
10065646
Insertion Portacath
Description

Organisation Portanlage

Data type

boolean

Alias
Code-1
Portacath insertion
UMLS CUI-1
C1868856
Appointment day hospital
Description

Termin onkologische Tagesklinik

Data type

boolean

Alias
Code-1
Appointment date (finding)
UMLS CUI-1
C0585085
SNOMED CT-1
185353001
Code-2
Day hospital (environment)
UMLS CUI-2
C0587438
SNOMED CT-2
274516006
Code-3
Oncologic (qualifier value)
UMLS CUI-3
C0205478
SNOMED CT-3
3428006
Appointment radiation therapy
Description

Termin in Strahlentherapie

Data type

boolean

Alias
Code-1
Appointment date (finding)
UMLS CUI-1
C0585085
SNOMED CT-1
185353001
Code-2
Therapeutic radiology procedure
UMLS CUI-2
C1522449
SNOMED CT-2
108290001
MedDRA-2
10037794
Information DMP
Description

Info über DMP erfolgt

Data type

boolean

Alias
Code-1
Information
UMLS CUI-1
CL414911
Code-2
Disease management program (regime/therapy)
UMLS CUI-2
C1303150
SNOMED CT-2
401173007
other
Description

Sonstiges

Data type

string

Alias
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
date physician
Description

Datum

Data type

date

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

Unterschrift

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
Admission date
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
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)
Geschlecht
Item
Patient sex
string
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
Nachname
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)
Geburtsdatum
Item
Patient date of birth
date
C0421451 (UMLS CUI-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)
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)
Item Group
Gespräch nach Tumorkonferenz
Patientin informiert
Item
date
date
Visit Date (Code-1)
C1320303 (UMLS CUI-1)
406543005 (SNOMED CT-1)
durch Dr.
Item
responsible person
string
Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
mit Empfehlung einverstanden
Item
Informed consent for decision cancer conference obtained
boolean
Informed consent obtained (Code-1)
C0514044 (UMLS CUI-1)
MTHU008888 (LOINC-1)
Cancer conference (Code-2)
C0805438 (UMLS CUI-2)
MTHU010336 (LOINC-2)
Decision (Code-3)
C0679006 (UMLS CUI-3)
wenn nein, folgende Abweichungen
Item
change of cancer conference decision
string
Change (Code-1)
C0392747 (UMLS CUI-1)
243326001 (SNOMED CT-1)
Decision (Code-2)
C0679006 (UMLS CUI-2)
Cancer conference (Code-3)
C0805438 (UMLS CUI-3)
MTHU010336 (LOINC-3)
Item
planned procedures
integer
Therapeutic procedure (Code-1)
C0087111 (UMLS CUI-1)
277132007 (SNOMED CT-1)
10053757 (MedDRA-1)
MTHU008880 (LOINC-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
weitere Maßnahmen wurden eingeleitet
Code List
planned procedures
CL Item
external therapy (nein, da weitere Therapie extern)
Extrinsic (Code-1)
C0205101 (UMLS CUI-1)
261074009 (SNOMED CT-1)
Therapeutic procedure (Code-2)
C0087111 (UMLS CUI-2)
277132007 (SNOMED CT-2)
10053757 (MedDRA-2)
MTHU008880 (LOINC-2)
CL Item
not required (nicht erforderlich)
Requirement (Code-1)
C1514873 (UMLS CUI-1)
Negation (Code-2)
C1518422 (UMLS CUI-2)
CL Item
Yes (ja)
Yes (Code-1)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
Aufklärung über Systemtherapie
Item
Patient informed systemic therapy
boolean
Informing patient (procedure) (Code-1)
C0588446 (UMLS CUI-1)
310866003 (SNOMED CT-1)
Systemic Therapy (Code-2)
C1515119 (UMLS CUI-2)
Aufklärung über Systemtherapie: endokrine Therapie
Item
Patient informed endocrin therapy
boolean
Informing patient (procedure) (Code-1)
C0588446 (UMLS CUI-1)
310866003 (SNOMED CT-1)
Endocrine Therapy (Code-2)
C0279025 (UMLS CUI-2)
169413002 (SNOMED CT-2)
10065646 (MedDRA-2)
Aufklärung über Systemtherapie: Chemotherapie
Item
Patient informed chemotherapy
boolean
Informing patient (procedure) (Code-1)
C0588446 (UMLS CUI-1)
310866003 (SNOMED CT-1)
Chemotherapy Regimen (Code-2)
C0392920 (UMLS CUI-2)
69960004 (SNOMED CT-2)
10061758 (MedDRA-2)
Aufklärung über Systemtherapie: Herceptin
Item
Patient informed immunotherapy
boolean
Informing patient (procedure) (Code-1)
C0588446 (UMLS CUI-1)
310866003 (SNOMED CT-1)
Immunotherapy (Code-2)
C0021083 (UMLS CUI-2)
76334006 (SNOMED CT-2)
Rp. Antihormonelle Therapie
Item
Prescriptions endocrine therapy
boolean
Drug Prescriptions (Code-1)
C0033081 (UMLS CUI-1)
182817000 (SNOMED CT-1)
MTHU035094 (LOINC-1)
Endocrine Therapy (Code-2)
C0279025 (UMLS CUI-2)
169413002 (SNOMED CT-2)
10065646 (MedDRA-2)
Infobogen endokrine Therapie ausgehändigt
Item
Information endocrine therapy
boolean
Information (Code-1)
CL414911 (UMLS CUI-1)
Endocrine Therapy (Code-2)
C0279025 (UMLS CUI-2)
169413002 (SNOMED CT-2)
10065646 (MedDRA-2)
Organisation Portanlage
Item
Insertion Portacath
boolean
Portacath insertion (Code-1)
C1868856 (UMLS CUI-1)
Termin onkologische Tagesklinik
Item
Appointment day hospital
boolean
Appointment date (finding) (Code-1)
C0585085 (UMLS CUI-1)
185353001 (SNOMED CT-1)
Day hospital (environment) (Code-2)
C0587438 (UMLS CUI-2)
274516006 (SNOMED CT-2)
Oncologic (qualifier value) (Code-3)
C0205478 (UMLS CUI-3)
3428006 (SNOMED CT-3)
Termin in Strahlentherapie
Item
Appointment radiation therapy
boolean
Appointment date (finding) (Code-1)
C0585085 (UMLS CUI-1)
185353001 (SNOMED CT-1)
Therapeutic radiology procedure (Code-2)
C1522449 (UMLS CUI-2)
108290001 (SNOMED CT-2)
10037794 (MedDRA-2)
Info über DMP erfolgt
Item
Information DMP
boolean
Information (Code-1)
CL414911 (UMLS CUI-1)
Disease management program (regime/therapy) (Code-2)
C1303150 (UMLS CUI-2)
401173007 (SNOMED CT-2)
Sonstiges
Item
other
string
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Datum
Item
date physician
date
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Unterschrift
Item
signature
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
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