HIS radiotherapy form prostate cancer

ID

4108

Beschreibung

HIS form from Soarian. Urologie Erlangen" with friendly permission of the urology Erlangen (Prof. Wullich) and the medical informatics department Erlangen (PD Dr. Bürkle)

Stichworte

EHR

Strahlentherapie

Routine documentation

Prostatatumoren

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

1 Formulare

StudyEvent: HIS
1. HIS

Admininstrative Daten

Beschreibung

Admininstrative Daten

Patient surname

Beschreibung

Name

Datentyp

string

Alias

UMLS CUI-1: C0421448

SNOMED CT-1: 184096005

Patient forename

Beschreibung

Vorname

Datentyp

string

Alias

UMLS CUI-1: C0421447

SNOMED CT-1: 184095009

Patient title

Beschreibung

Titel

Datentyp

string

Alias

Code-1: Patient title (observable entity)

UMLS CUI-1: C0421450

SNOMED CT-1: 184098006

former Patient name

Beschreibung

früherer Name

Datentyp

string

Alias

Code-1: Previous

UMLS CUI-1: C0205156

SNOMED CT-1: 9130008

Code-2: Patient name (observable entity)

UMLS CUI-2: C1299487

SNOMED CT-2: 371484003

Patient date of birth

Beschreibung

Geburtsdatum

Datentyp

date

Alias

UMLS CUI-1: C0421451

SNOMED CT-1: 184099003

patient age

Beschreibung

Alter

Datentyp

integer

Alias

Code-1: patient age

UMLS CUI-1: CL386174

Ethnicity / related nationality data

Beschreibung

Nationalität

Datentyp

string

Alias

UMLS CUI-1: C0438960

SNOMED CT-1: 186034007

Code-2: Patients

UMLS CUI-2: C0030705

SNOMED CT-2: 116154003

Street Address

Beschreibung

Adresse

Datentyp

string

Alias

UMLS CUI-1: C1301826

SNOMED CT-1: 398099009

Code-2: Patient address

UMLS CUI-2: C0421449

SNOMED CT-2: 184097001

Patient postal code

Beschreibung

PLZ

Datentyp

integer

Alias

UMLS CUI-1: C0421454

SNOMED CT-1: 184102003

City of residence

Beschreibung

Stadt

Datentyp

string

Alias

UMLS CUI-1: C2316883

SNOMED CT-1: 433178008

Code-2: Patient address

UMLS CUI-2: C0421449

SNOMED CT-2: 184097001

Case Identifier

Beschreibung

Fallnummer

Datentyp

integer

Alias

Code-1: Case - situation (qualifier value)

UMLS CUI-1: C0868928

SNOMED CT-1: 398241000

Code-2: Identifier

UMLS CUI-2: C0600091

SNOMED CT-2: 118522005

Tumordiagnose

Beschreibung

Tumordiagnose

Cancer Diagnosis

Beschreibung

Tumordiagnose (ICD-10)

Datentyp

string

Alias

Code-1: Tumor finding (finding)

UMLS CUI-1: C1274082

SNOMED CT-1: 395557000

Code-2: Diagnosis ICD code

UMLS CUI-2: C2598420

Date of diagnosis

Beschreibung

Diagnose-Datum

Datentyp

date

Alias

UMLS CUI-1: C2316983

SNOMED CT-1: 432213005

Code-2: Tumor finding (finding)

UMLS CUI-2: C1274082

SNOMED CT-2: 395557000

Therapeutic radiology procedure

Beschreibung

Therapeutic radiology procedure

Guideline Adherence

Beschreibung

Wird die Therapie nach Leitlinien durchgeführt

Datentyp

boolean

Alias

Item-Info: must_have

UMLS CUI-1: C0525059

Yes

Reason for Guidelines Adherence

Beschreibung

falls nein

Datentyp

string

Alias

Code-1: Indication of (contextual qualifier)

UMLS CUI-1: C0392360

SNOMED CT-1: 410666004

LOINC-1: MTHU008862

Code-2: Guideline Adherence

UMLS CUI-2: C0525059

Tumortherapie allgemein

Beschreibung

Tumortherapie allgemein

Intent

Beschreibung

Intention

Datentyp

integer

Alias

UMLS CUI-1: C1283828

SNOMED CT-1: 367565008

Code-2: Therapeutic radiology procedure

UMLS CUI-2: C1522449

SNOMED CT-2: 108290001

MedDRA-2: 10037794

Curative - procedure intent (kurativ)

Palliative - procedure intent (palliativ)

Adjuvant - intent (adjuvant)

Neo-adjuvant - intent (neoadjuvant)

Therapiebeurteilung

Beschreibung

Therapiebeurteilung

Termination of Radiotherapy

Beschreibung

Beendigung der Strahlentherapie

Datentyp

integer

Alias

Item-Info: must_have

Code-1: Radiotherapy stopped (situation)

UMLS CUI-1: C0436384

SNOMED CT-1: 168533005

regular End of Therapy (reguläres Ende)

Discontinue because of adverse effects (Abbruch wegen Nebenwirkungen)

Refusal of Treatment (Patient verweigert die Therapie)

ECOG performance status grade

Beschreibung

Allgemeiner Leistungszustand (nach ECOG)

Datentyp

integer

Alias

UMLS CUI-1: C1632812

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HIS

1 Formulare

StudyEvent: HIS
1. HIS

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Admininstrative Daten

Item Group

Admininstrative Daten

Name

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)

Titel

Item

Patient title

string

Patient title (observable entity) (Code-1)
C0421450 (UMLS CUI-1)
184098006 (SNOMED CT-1)

früherer Name

Item

former Patient name

string

Previous (Code-1)
C0205156 (UMLS CUI-1)
9130008 (SNOMED CT-1)
Patient name (observable entity) (Code-2)
C1299487 (UMLS CUI-2)
371484003 (SNOMED CT-2)

Geburtsdatum

Item

Patient date of birth

date

C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)

Alter

Item

patient age

integer

patient age (Code-1)
CL386174 (UMLS CUI-1)

Nationalität

Item

Ethnicity / related nationality data

string

C0438960 (UMLS CUI-1)
186034007 (SNOMED CT-1)
Patients (Code-2)
C0030705 (UMLS CUI-2)
116154003 (SNOMED CT-2)

Adresse

Item

Street Address

string

C1301826 (UMLS CUI-1)
398099009 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)

PLZ

Item

Patient postal code

integer

C0421454 (UMLS CUI-1)
184102003 (SNOMED CT-1)

Stadt

Item

City of residence

string

C2316883 (UMLS CUI-1)
433178008 (SNOMED CT-1)
Patient address (Code-2)
C0421449 (UMLS CUI-2)
184097001 (SNOMED CT-2)

Fallnummer

Item

Case Identifier

integer

Case - situation (qualifier value) (Code-1)
C0868928 (UMLS CUI-1)
398241000 (SNOMED CT-1)
Identifier (Code-2)
C0600091 (UMLS CUI-2)
118522005 (SNOMED CT-2)

Tumordiagnose

Item Group

Tumordiagnose

Tumordiagnose (ICD-10)

Item

Cancer Diagnosis

string

Tumor finding (finding) (Code-1)
C1274082 (UMLS CUI-1)
395557000 (SNOMED CT-1)
Diagnosis ICD code (Code-2)
C2598420 (UMLS CUI-2)

Diagnose-Datum

Item

Date of diagnosis

date

C2316983 (UMLS CUI-1)
432213005 (SNOMED CT-1)
Tumor finding (finding) (Code-2)
C1274082 (UMLS CUI-2)
395557000 (SNOMED CT-2)

Strahlentherapie

Item Group

Therapeutic radiology procedure

Wird die Therapie nach Leitlinien durchgeführt

Item

Guideline Adherence

boolean

must_have (Item-Info)
C0525059 (UMLS CUI-1)

falls nein

Item

Reason for Guidelines Adherence

string

Indication of (contextual qualifier) (Code-1)
C0392360 (UMLS CUI-1)
410666004 (SNOMED CT-1)
MTHU008862 (LOINC-1)
Guideline Adherence (Code-2)
C0525059 (UMLS CUI-2)

Tumortherapie allgemein

Item Group

Tumortherapie allgemein

Intention

Item

Intent

integer

C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Therapeutic radiology procedure (Code-2)
C1522449 (UMLS CUI-2)
108290001 (SNOMED CT-2)
10037794 (MedDRA-2)

Intention

Code List

Intent

CL Item

Curative - procedure intent (kurativ)

Curative - procedure intent (qualifier value) (Code-1)
C1276305 (UMLS CUI-1)
373808002 (SNOMED CT-1)

CL Item

Palliative - procedure intent (palliativ)

Palliative - procedure intent (qualifier value) (Code-1)
C1285530 (UMLS CUI-1)
363676003 (SNOMED CT-1)

CL Item

Adjuvant - intent (adjuvant)

Adjuvant - intent (qualifier value) (Code-1)
C1298675 (UMLS CUI-1)
373846009 (SNOMED CT-1)

CL Item

Neo-adjuvant - intent (neoadjuvant)

Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)

Bestrahlung

Item Group

Bestrahlung

Zielgebiet

Item

Organ target(s)

integer

must_have (Item-Info)
C0807185 (UMLS CUI-1)

Zielgebiet

Code List

Organ target(s)

CL Item

Prostate (Prostata)

Prostate (Code-1)
C0033572 (UMLS CUI-1)
41216001 (SNOMED CT-1)
MTHU004957 (LOINC-1)

CL Item

not_useful_for_research (Prostata + LK kleines Becken)

CL Item

not_useful_for_research (Prostata + pelvine paraaortale LK im Bauchraum)

CL Item

not_useful_for_research (Prostataloge)

CL Item

not_useful_for_research (Prostataloge + LK kleines Becken)

CL Item

not_useful_for_research (Prostataloge + pelvine paraaortale LK im Bauchraum)

CL Item

not_useful_for_research (sonstiges)

CL Item

Sonstiges (Other)

C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)

Technik

Item

Radiotherapy Technique

integer

must_have (Item-Info)
Technique (Code-1)
C0449851 (UMLS CUI-1)
246501002 (SNOMED CT-1)
Therapeutic radiology procedure (Code-2)
C1522449 (UMLS CUI-2)
108290001 (SNOMED CT-2)
10037770 (MedDRA-2)

Technik

Code List

Radiotherapy Technique

CL Item

Teleradiotherapy procedure (percutane Strahlentherapie)

Teleradiotherapy procedure (procedure) (Code-1)
C0419095 (UMLS CUI-1)
33195004 (SNOMED CT-1)

CL Item

PDR temporary Brachytherapy (PDR temporäre Brachytherapie)

Brachytherapy (Code-1)
C0006098 (UMLS CUI-1)
399315003 (SNOMED CT-1)
10061018 (MedDRA-1)
Temporary (Code-2)
C0205374 (UMLS CUI-2)
14803004 (SNOMED CT-2)
pulsed-dose rate brachytherapy (Code-3)
CL413609 (UMLS CUI-3)

CL Item

HDR temporary Brachytherapy (HDR temporäre Brachytherapie)

Brachytherapy (Code-1)
C0006098 (UMLS CUI-1)
399315003 (SNOMED CT-1)
10061018 (MedDRA-1)
Temporary (Code-2)
C0205374 (UMLS CUI-2)
14803004 (SNOMED CT-2)
High-Dose Rate Brachytherapy (Code-3)
C0454270 (UMLS CUI-3)
228867005 (SNOMED CT-3)

CL Item

Brachytherapy (Brachytherapie)

Brachytherapy (Code-1)
C0006098 (UMLS CUI-1)
399315003 (SNOMED CT-1)
10061018 (MedDRA-1)

Strahlenart

Item

Radiation

integer

for_compare (Code-Info)
C0851346 (UMLS CUI-1)
82107009 (SNOMED CT-1)
MTHU026213 (LOINC-1)

Strahlenart

Code List

Radiation

CL Item

Iridium 192 (IR-Iridium-192)

^192^Iridium (substance) (Code-1)
C0303472 (UMLS CUI-1)
48341001 (SNOMED CT-1)

CL Item

Iodine-125 (J1-Jod-125)

Iodine-125 (Code-1)
C0796396 (UMLS CUI-1)
68630002 (SNOMED CT-1)

CL Item

Palladium Pd-103 (Palladium Pd-103 )

Palladium Pd-103 (Code-1)
C0303566 (UMLS CUI-1)
9351000 (SNOMED CT-1)

Begonnen am

Item

Start Radiotherapy

date

Radiotherapy started (situation) (Code-1)
C0436382 (UMLS CUI-1)
168531007 (SNOMED CT-1)

Ende am

Item

End Radiotherapy

date

Radiotherapy completed (situation) (Code-1)
C0436385 (UMLS CUI-1)
168534004 (SNOMED CT-1)

Gesamtdosis

Item

total amount of radiation

string

Radiotherapy Dosage (Code-1)
C0034620 (UMLS CUI-1)

Therapiebeurteilung

Item Group

Therapiebeurteilung

Beendigung der Strahlentherapie

Item

Termination of Radiotherapy

integer

must_have (Item-Info)
Radiotherapy stopped (situation) (Code-1)
C0436384 (UMLS CUI-1)
168533005 (SNOMED CT-1)

Beendigung der Strahlentherapie

Code List

Termination of Radiotherapy

CL Item

regular End of Therapy (reguläres Ende)

Regular (Code-1)
C0449581 (UMLS CUI-1)
17854005 (SNOMED CT-1)
End (Code-2)
C1272693 (UMLS CUI-2)
385656004 (SNOMED CT-2)

CL Item

Discontinue because of adverse effects (Abbruch wegen Nebenwirkungen)

Adverse effects (Code-1)
C0879626 (UMLS CUI-1)
281647001 (SNOMED CT-1)
10067484 (MedDRA-1)
Discontinue (Code-2)
C1444662 (UMLS CUI-2)
410546004 (SNOMED CT-2)
Indication of (contextual qualifier) (Code-3)
C0392360 (UMLS CUI-3)
230165009 (SNOMED CT-3)
MTHU008319 (LOINC-3)

CL Item

Refusal of Treatment (Patient verweigert die Therapie)

C0040809 (UMLS CUI-1)
105480006 (SNOMED CT-1)
10056407 (MedDRA-1)

Allgemeiner Leistungszustand (nach ECOG)

Item

ECOG performance status grade

integer

C1632812 (UMLS CUI-1)

Allgemeiner Leistungszustand (nach ECOG)

Code List

ECOG performance status grade

CL Item

0 (0)

Eastern Cooperative Oncology Group performance status - grade 0 (finding) (Code-1)
C1828078 (UMLS CUI-1)
25389002 (SNOMED CT-1)

CL Item

1 (1)

Eastern Cooperative Oncology Group performance status - grade 1 (finding) (Code-1)
C1827388 (UMLS CUI-1)
422512005 (SNOMED CT-1)

CL Item

2 (2)

Eastern Cooperative Oncology Group performance status - grade 2 (finding) (Code-1)
C1828242 (UMLS CUI-1)
422894000 (SNOMED CT-1)

CL Item

3 (3)

Eastern Cooperative Oncology Group performance status - grade 3 (finding) (Code-1)
C1827126 (UMLS CUI-1)
423053003 (SNOMED CT-1)

CL Item

4 (4)

Eastern Cooperative Oncology Group performance status - grade 4 (finding) (Code-1)
C1827528 (UMLS CUI-1)
423237006 (SNOMED CT-1)

Nebenwirkungen nach CTC (Common Toxicity Criteria)

Item Group

Common Terminology Criteria for Adverse Events

Nebenwirkungen

Item

Adverse event

boolean

for_compare (Code-Info)
C0877248 (UMLS CUI-1)
10060933 (MedDRA-1)
MTHU014542 (LOINC-1)

Niere/Blase

Item

Genitourinary system

integer

Renal or Genitourinary Other Adverse Event (Code-1)
C1558061 (UMLS CUI-1)
MTHU117419 (CTCAE-1)

Niere/Blase

Code List

Genitourinary system

CL Item

no adverse event (0 = keine Nebenwirkungen)

Absent Adverse Event (Code-1)
C2699517 (UMLS CUI-1)

CL Item

mild adverse event (1 = geringe/leichte Nebenwirkungen)

Mild Adverse Event (Code-1)
C1513302 (UMLS CUI-1)

CL Item

moderate adverse event (2 = mäßige / deutliche Nebenwirkungen)

Moderate Adverse Event (Code-1)
C1513374 (UMLS CUI-1)

CL Item

strong adverse event (3 = starke / ausgeprägte Nebenwirkungen)

Severe Adverse Event (Code-1)
C1519275 (UMLS CUI-1)

CL Item

Life Threatening adverse event (4 = lebensbedrohliche Nebenwirkungen)

Life Threatening Adverse Event (Code-1)
C1517874 (UMLS CUI-1)

CL Item

unknown adverse event (X = Grad der Nebenwirkungen unbekannt)

Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)

Gastrointestinaltrakt

Item

Gastrointestinal system

integer

Adverse Event Associated with the Gastrointestinal System (Code-1)
C1559265 (UMLS CUI-1)
MTHU112146 (CTCAE-1)

Gastrointestinaltrakt

Code List

Gastrointestinal system

CL Item

no adverse event (0 = keine Nebenwirkungen)

Absent Adverse Event (Code-1)
C2699517 (UMLS CUI-1)

CL Item

mild adverse event (1 = geringe/leichte Nebenwirkungen)

Mild Adverse Event (Code-1)
C1513302 (UMLS CUI-1)

CL Item

moderate adverse event (2 = mäßige / deutliche Nebenwirkungen)

Moderate Adverse Event (Code-1)
C1513374 (UMLS CUI-1)

CL Item

strong adverse event (3 = starke / ausgeprägte Nebenwirkungen)

Severe Adverse Event (Code-1)
C1519275 (UMLS CUI-1)

CL Item

Life Threatening adverse event (4 = lebensbedrohliche Nebenwirkungen)

Life Threatening Adverse Event (Code-1)
C1517874 (UMLS CUI-1)

CL Item

unknown adverse event (X = Grad der Nebenwirkungen unbekannt)

Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)

Fieber

Item

Fever

integer

Fever Without Neutropenia Adverse Event (Code-1)
C1556366 (UMLS CUI-1)
MTHU116933 (CTCAE-1)

Fieber

Code List

Fever

CL Item

no adverse event (0 = keine)

Absent Adverse Event (Code-1)
C2699517 (UMLS CUI-1)

CL Item

mild adverse event (1 = gering/leicht)

Mild Adverse Event (Code-1)
C1513302 (UMLS CUI-1)

CL Item

moderate adverse event (2 = mäßig/deutlich)

Moderate Adverse Event (Code-1)
C1513374 (UMLS CUI-1)

CL Item

strong adverse event (3 = stark/ausgeprägt)

Severe Adverse Event (Code-1)
C1519275 (UMLS CUI-1)

CL Item

Life Threatening adverse event (4 = lebensbedrohlich)

Life Threatening Adverse Event (Code-1)
C1517874 (UMLS CUI-1)

CL Item

unknown adverse event (X = Nebenwirkungen unbekannt)

Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)

CL Item

only in connection with Infection (only in connection with Infection)

Infektion

Item

Infection

integer

Adverse Event Associated with Infection (Code-1)
C1556682 (UMLS CUI-1)
MTHU112135 (CTCAE-1)

Infektion

Code List

Infection

CL Item

no adverse event (0 = keine)

Absent Adverse Event (Code-1)
C2699517 (UMLS CUI-1)

CL Item

mild adverse event (1 = gering/leicht)

Mild Adverse Event (Code-1)
C1513302 (UMLS CUI-1)

CL Item

moderate adverse event (2 = mäßig/deutlich)

Moderate Adverse Event (Code-1)
C1513374 (UMLS CUI-1)

CL Item

strong adverse event (3 = stark/ausgeprägt)

Severe Adverse Event (Code-1)
C1519275 (UMLS CUI-1)

CL Item

Life Threatening adverse event (4 = lebensbedrohlich)

Life Threatening Adverse Event (Code-1)
C1517874 (UMLS CUI-1)

CL Item

unknown adverse event (X = Nebenwirkungen unbekannt)

Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)

CL Item

only in connection with fever (only in connection with fever)

Laborwerte

Item

Laboratory Values

integer

Other Metabolic and Laboratory Adverse Event (Code-1)
C1559945 (UMLS CUI-1)
MTHU117254 (CTCAE-1)

Laborwerte

Code List

Laboratory Values

CL Item

no adverse event (0 = keine Nebenwirkungen)

Absent Adverse Event (Code-1)
C2699517 (UMLS CUI-1)

CL Item

mild adverse event (1 = geringe/leichte Nebenwirkungen)

Mild Adverse Event (Code-1)
C1513302 (UMLS CUI-1)

CL Item

moderate adverse event (2 = mäßige / deutliche Nebenwirkungen)

Moderate Adverse Event (Code-1)
C1513374 (UMLS CUI-1)

CL Item

strong adverse event (3 = starke / ausgeprägte Nebenwirkungen)

Severe Adverse Event (Code-1)
C1519275 (UMLS CUI-1)

CL Item

Life Threatening adverse event (4 = lebensbedrohliche Nebenwirkungen)

Life Threatening Adverse Event (Code-1)
C1517874 (UMLS CUI-1)

CL Item

unknown adverse event (X = Grad der Nebenwirkungen unbekannt)

Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)

Sonstige

Item

other adverse event

integer

Adverse event (Code-1)
C0877248 (UMLS CUI-1)
10060933 (MedDRA-1)
MTHU014542 (LOINC-1)

Sonstige

Code List

other adverse event

CL Item

no adverse event (0 = keine Nebenwirkungen)

Absent Adverse Event (Code-1)
C2699517 (UMLS CUI-1)

CL Item

mild adverse event (1 = geringe/leichte Nebenwirkungen)

Mild Adverse Event (Code-1)
C1513302 (UMLS CUI-1)

CL Item

moderate adverse event (2 = mäßige / deutliche Nebenwirkungen)

Moderate Adverse Event (Code-1)
C1513374 (UMLS CUI-1)

CL Item

strong adverse event (3 = starke / ausgeprägte Nebenwirkungen)

Severe Adverse Event (Code-1)
C1519275 (UMLS CUI-1)

CL Item

Life Threatening adverse event (4 = lebensbedrohliche Nebenwirkungen)

Life Threatening Adverse Event (Code-1)
C1517874 (UMLS CUI-1)

CL Item

unknown adverse event (X = Grad der Nebenwirkungen unbekannt)

Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)

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ID

Beschreibung

Stichworte

Versionen (1)

Hochgeladen am

DOI

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