ID

4087

Descrição

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

Palavras-chave

Versões (1)
  1. 07/08/2013 07/08/2013 -
Transferido a

7 de agosto de 2013

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

HIS Talk after conference breast cancer

Alemão Inglês

HIS

1 Formulários  
  1. StudyEvent: HIS
    1. HIS
Patientenaufkleber groß
Descrição

Patientenaufkleber groß

Admission date
Descrição

Aufnahmedatum

Tipo de dados

date

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

PatientenID

Tipo de dados

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
Descrição

Geschlecht

Tipo de dados

string

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

Nachname

Tipo de dados

string

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

Vorname

Tipo de dados

string

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

Geburtsdatum

Tipo de dados

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Admission hour
Descrição

Aufnahmezeit

Tipo de dados

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
Descrição

E-Arzt

Tipo de dados

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
Descrição

Gespräch nach Tumorkonferenz

date
Descrição

Patientin informiert

Tipo de dados

date

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

durch Dr.

Tipo de dados

string

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

mit Empfehlung einverstanden

Tipo de dados

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
Descrição

wenn nein, folgende Abweichungen

Tipo de dados

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
Descrição

weitere Maßnahmen wurden eingeleitet

Tipo de dados

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
Descrição

Aufklärung über Systemtherapie

Tipo de dados

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
Descrição

Aufklärung über Systemtherapie: endokrine Therapie

Tipo de dados

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
Descrição

Aufklärung über Systemtherapie: Chemotherapie

Tipo de dados

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
Descrição

Aufklärung über Systemtherapie: Herceptin

Tipo de dados

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
Descrição

Rp. Antihormonelle Therapie

Tipo de dados

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
Descrição

Infobogen endokrine Therapie ausgehändigt

Tipo de dados

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
Descrição

Organisation Portanlage

Tipo de dados

boolean

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

Termin onkologische Tagesklinik

Tipo de dados

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
Descrição

Termin in Strahlentherapie

Tipo de dados

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
Descrição

Info über DMP erfolgt

Tipo de dados

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
Descrição

Sonstiges

Tipo de dados

string

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

Datum

Tipo de dados

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
Descrição

Unterschrift

Tipo de dados

string

Alias
Code-1
Signature of responsible attending physician on file
UMLS CUI-1
C0807938
Voltar ao início da página

Similar models

HIS

1 Formulários
  1. StudyEvent: HIS
    1. HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
Voltar ao início da página 

Contacto

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Ajuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial