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ID

4110

Description

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

Keywords

Versions (1)
  1. 8/7/13 8/7/13 -
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August 7, 2013

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Creative Commons BY-NC 3.0 Legacy
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    HIS surgery form prostate cancer

    German English

    HIS

    1 forms  
    1. StudyEvent: HIS
      1. HIS
    Admininstrative Daten
    Description

    Admininstrative Daten

    Patient surname
    Description

    Name

    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 title
    Description

    Titel

    Data type

    string

    Alias
    Code-1
    Patient title (observable entity)
    UMLS CUI-1
    C0421450
    SNOMED CT-1
    184098006
    former Patient name
    Description

    früherer Name

    Data type

    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
    Description

    Geburtsdatum

    Data type

    date

    Alias
    UMLS CUI-1
    C0421451
    SNOMED CT-1
    184099003
    patient age
    Description

    Alter

    Data type

    integer

    Alias
    Code-1
    patient age
    UMLS CUI-1
    CL386174
    Ethnicity / related nationality data
    Description

    Nationalität

    Data type

    string

    Alias
    UMLS CUI-1
    C0438960
    SNOMED CT-1
    186034007
    Code-2
    Patients
    UMLS CUI-2
    C0030705
    SNOMED CT-2
    116154003
    Street Address
    Description

    Adresse

    Data type

    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
    Description

    PLZ

    Data type

    integer

    Alias
    UMLS CUI-1
    C0421454
    SNOMED CT-1
    184102003
    City of residence
    Description

    Stadt

    Data type

    string

    Alias
    UMLS CUI-1
    C2316883
    SNOMED CT-1
    433178008
    Code-2
    Patient address
    UMLS CUI-2
    C0421449
    SNOMED CT-2
    184097001
    Case Identifier
    Description

    Fallnummer

    Data type

    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
    OP-Bogen
    Description

    OP-Bogen

    Cancer Diagnosis
    Description

    Tumordiagnose (ICD-10)

    Data type

    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
    Description

    Diagnose-Datum

    Data type

    date

    Alias
    UMLS CUI-1
    C2316983
    SNOMED CT-1
    432213005
    Code-2
    Tumor finding (finding)
    UMLS CUI-2
    C1274082
    SNOMED CT-2
    395557000
    Date of surgery
    Description

    Datum

    Data type

    date

    Alias
    Code-1
    Date surgery
    UMLS CUI-1
    C1628561
    LOINC-1
    MTHU019327
    Guideline Adherence
    Description

    Wird die Therapie nach Leitlinien durchgeführt

    Data type

    boolean

    Alias
    Item-Info
    must_have
    UMLS CUI-1
    C0525059
    Reason for Guidelines Adherence
    Description

    Grund

    Data type

    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
    ASA physical status
    Description

    ASA

    Data type

    integer

    Alias
    Code-1
    Finding of American Society of Anesthesiologists physical status classification (finding)
    UMLS CUI-1
    C1531480
    SNOMED CT-1
    413347006
    Operative Surgical Procedure
    Description

    Operative Surgical Procedure

    Surgical and medical procedures
    Description

    OPS-2010

    Data type

    string

    Alias
    Item-Info
    must_have
    Code-1
    Surgical and medical procedures
    UMLS CUI-1
    C1948041
    SNOMED CT-1
    71388002
    LOINC-1
    MTHU006237
    Side
    Description

    Seite

    Data type

    integer

    Alias
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Tumor site
    UMLS CUI-2
    C0475445
    SNOMED CT-2
    263591006
    LOINC-2
    MTHU015562
    Intent
    Description

    Ziel

    Data type

    integer

    Alias
    UMLS CUI-1
    C1283828
    SNOMED CT-1
    367565008
    Code-2
    Operative Surgical Procedures
    UMLS CUI-2
    C0543467
    SNOMED CT-2
    387713003
    MedDRA-2
    10042609
    LOINC-2
    MTHU007597
    Which Operative Surgical Procedures
    Description

    welche

    Data type

    string

    Alias
    Code-1
    Operative Surgical Procedures
    UMLS CUI-1
    C0543467
    SNOMED CT-1
    387713003
    MedDRA-1
    10042609
    LOINC-1
    MTHU007597
    Code-2
    Free Text Format
    UMLS CUI-2
    C2348713
    Nerve-Sparing
    Description

    Nerverhalt

    Data type

    boolean

    Alias
    Code-1
    Nerve-Sparing Prostatectomy
    UMLS CUI-1
    C1514120
    Side
    Description

    falls ja, wo?

    Data type

    integer

    Alias
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Nerve-Sparing Prostatectomy
    UMLS CUI-2
    C1514120
    primary surgeon
    Description

    Name des Operateurs

    Data type

    string

    Alias
    Item-Info
    must_have
    UMLS CUI-1
    C0808118
    LOINC-1
    MTHU010488
    HL7 V3-1
    PRISURG
    first assistant surgeon
    Description

    Lehrassistenz

    Data type

    string

    Alias
    UMLS CUI-1
    C1550491
    HL7 V3-1
    FASST
    additional surgery
    Description

    Weitere OP

    Data type

    string

    Alias
    Code-1
    Additional
    UMLS CUI-1
    C1524062
    Code-2
    Operative Surgical Procedures
    UMLS CUI-2
    C0543467
    SNOMED CT-2
    387713003
    MedDRA-2
    10042609
    LOINC-2
    MTHU007597
    Surgical and medical procedures
    Description

    OPS-2010 (weitere OP)

    Data type

    string

    Alias
    Code-1
    Surgical and medical procedures
    UMLS CUI-1
    C1948041
    SNOMED CT-1
    71388002
    LOINC-1
    MTHU006237
    Side
    Description

    Seite

    Data type

    integer

    Alias
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Additional
    UMLS CUI-2
    C1524062
    Code-3
    Operative Surgical Procedures
    UMLS CUI-3
    C0543467
    SNOMED CT-3
    387713003
    MedDRA-3
    10042609
    LOINC-3
    MTHU007597
    Intent
    Description

    Ziel

    Data type

    integer

    Alias
    UMLS CUI-1
    C1283828
    SNOMED CT-1
    367565008
    Code-2
    Additional
    UMLS CUI-2
    C1524062
    Code-3
    Operative Surgical Procedures
    UMLS CUI-3
    C0543467
    SNOMED CT-3
    387713003
    MedDRA-3
    10042609
    LOINC-3
    MTHU007597
    Intraoperative Complication
    Description

    intraoperative Komplikationen

    Data type

    boolean

    Alias
    Item-Info
    must_have
    UMLS CUI-1
    C0021890
    MedDRA-1
    10052620
    Which Intraoperative Complication
    Description

    falls ja, welche

    Data type

    string

    Alias
    UMLS CUI-1
    C0021890
    MedDRA-1
    10052620
    Code-2
    Free Text Format
    UMLS CUI-2
    C2348713
    Back to the top of the page

    Similar models

    HIS

    1 forms
    1. StudyEvent: HIS
      1. HIS
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    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)
    Item Group
    OP-Bogen
    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)
    Datum
    Item
    Date of surgery
    date
    Date surgery (Code-1)
    C1628561 (UMLS CUI-1)
    MTHU019327 (LOINC-1)
    Wird die Therapie nach Leitlinien durchgeführt
    Item
    Guideline Adherence
    boolean
    must_have (Item-Info)
    C0525059 (UMLS CUI-1)
    Grund
    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)
    Item
    ASA physical status
    integer
    Finding of American Society of Anesthesiologists physical status classification (finding) (Code-1)
    C1531480 (UMLS CUI-1)
    413347006 (SNOMED CT-1)
    ASA
    Code List
    ASA physical status
    CL Item
    ASA physical status 1 (ASA I: Normaler, gesunder Patient)
    American Society of Anesthesiologists physical status class 1 (finding) (Code-1)
    C1531504 (UMLS CUI-1)
    413495001 (SNOMED CT-1)
    CL Item
    ASA physical status 2 (ASA II: Patient mit leichter Allgemeinerkrankung)
    American Society of Anesthesiologists physical status class 2 (finding) (Code-1)
    C1531505 (UMLS CUI-1)
    413496000 (SNOMED CT-1)
    CL Item
    ASA physical status 3 (ASA III: Patient mit schwerer Allgemeinerkrankung)
    American Society of Anesthesiologists physical status class 3 (finding) (Code-1)
    C1531506 (UMLS CUI-1)
    413497009 (SNOMED CT-1)
    CL Item
    ASA physical status 4 (ASA IV: Patient mit lebensbedrohlicher Allgemeinerkrankung)
    American Society of Anesthesiologists physical status class 4 (finding) (Code-1)
    C1531507 (UMLS CUI-1)
    413498004 (SNOMED CT-1)
    Item Group
    Operative Surgical Procedure
    OPS-2010
    Item
    Surgical and medical procedures
    string
    must_have (Item-Info)
    Surgical and medical procedures (Code-1)
    C1948041 (UMLS CUI-1)
    71388002 (SNOMED CT-1)
    MTHU006237 (LOINC-1)
    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)
    Seite
    Code List
    Side
    CL Item
    Unilateral  (einiseitg)
    Unilateral (Code-1)
    C0205092 (UMLS CUI-1)
    66459002 (SNOMED CT-1)
    CL Item
    Bilateral (zweiseitig)
    Bilateral (Code-1)
    C0238767 (UMLS CUI-1)
    51440002 (SNOMED CT-1)
    Item
    Intent
    integer
    C1283828 (UMLS CUI-1)
    367565008 (SNOMED CT-1)
    Operative Surgical Procedures (Code-2)
    C0543467 (UMLS CUI-2)
    387713003 (SNOMED CT-2)
    10042609 (MedDRA-2)
    MTHU007597 (LOINC-2)
    Ziel
    Code List
    Intent
    CL Item
    Curative - procedure intent  (K = kurativ)
    Curative - procedure intent (qualifier value) (Code-1)
    C1276305 (UMLS CUI-1)
    373808002 (SNOMED CT-1)
    CL Item
    Palliative - procedure intent  (P = palliativ)
    Palliative - procedure intent (qualifier value) (Code-1)
    C1285530 (UMLS CUI-1)
    363676003 (SNOMED CT-1)
    CL Item
    Diagnostic intent (D = diagnostisch)
    Intent For Diagnosis (Code-1)
    C0348026 (UMLS CUI-1)
    261004008 (SNOMED CT-1)
    CL Item
    unknown (unbekannt)
    Unknown (Code-1)
    C0439673 (UMLS CUI-1)
    261665006 (SNOMED CT-1)
    welche
    Item
    Which Operative Surgical Procedures
    string
    Operative Surgical Procedures (Code-1)
    C0543467 (UMLS CUI-1)
    387713003 (SNOMED CT-1)
    10042609 (MedDRA-1)
    MTHU007597 (LOINC-1)
    Free Text Format (Code-2)
    C2348713 (UMLS CUI-2)
    Nerverhalt
    Item
    Nerve-Sparing
    boolean
    Nerve-Sparing Prostatectomy (Code-1)
    C1514120 (UMLS CUI-1)
    Item
    Side
    integer
    C0441987 (UMLS CUI-1)
    182353008 (SNOMED CT-1)
    MTHU014973 (LOINC-1)
    Nerve-Sparing Prostatectomy (Code-2)
    C1514120 (UMLS CUI-2)
    falls ja, wo?
    Code List
    Side
    CL Item
    Right (rechts)
    C0205090 (UMLS CUI-1)
    24028007 (SNOMED CT-1)
    CL Item
    Left (links)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    CL Item
    Bilateral (beidseits)
    C0238767 (UMLS CUI-1)
    51440002 (SNOMED CT-1)
    Name des Operateurs
    Item
    primary surgeon
    string
    must_have (Item-Info)
    C0808118 (UMLS CUI-1)
    MTHU010488 (LOINC-1)
    PRISURG (HL7 V3-1)
    Lehrassistenz
    Item
    first assistant surgeon
    string
    C1550491 (UMLS CUI-1)
    FASST (HL7 V3-1)
    Weitere OP
    Item
    additional surgery
    string
    Additional (Code-1)
    C1524062 (UMLS CUI-1)
    Operative Surgical Procedures (Code-2)
    C0543467 (UMLS CUI-2)
    387713003 (SNOMED CT-2)
    10042609 (MedDRA-2)
    MTHU007597 (LOINC-2)
    OPS-2010 (weitere OP)
    Item
    Surgical and medical procedures
    string
    Surgical and medical procedures (Code-1)
    C1948041 (UMLS CUI-1)
    71388002 (SNOMED CT-1)
    MTHU006237 (LOINC-1)
    Item
    Side
    integer
    C0441987 (UMLS CUI-1)
    182353008 (SNOMED CT-1)
    MTHU014973 (LOINC-1)
    Additional (Code-2)
    C1524062 (UMLS CUI-2)
    Operative Surgical Procedures (Code-3)
    C0543467 (UMLS CUI-3)
    387713003 (SNOMED CT-3)
    10042609 (MedDRA-3)
    MTHU007597 (LOINC-3)
    Seite
    Code List
    Side
    CL Item
    Unilateral  (einiseitg)
    Unilateral (Code-1)
    C0205092 (UMLS CUI-1)
    66459002 (SNOMED CT-1)
    CL Item
    Bilateral (zweiseitig)
    Bilateral (Code-1)
    C0238767 (UMLS CUI-1)
    51440002 (SNOMED CT-1)
    Item
    Intent
    integer
    C1283828 (UMLS CUI-1)
    367565008 (SNOMED CT-1)
    Additional (Code-2)
    C1524062 (UMLS CUI-2)
    Operative Surgical Procedures (Code-3)
    C0543467 (UMLS CUI-3)
    387713003 (SNOMED CT-3)
    10042609 (MedDRA-3)
    MTHU007597 (LOINC-3)
    Ziel
    Code List
    Intent
    CL Item
    Curative - procedure intent  (K = kurativ)
    Curative - procedure intent (qualifier value) (Code-1)
    C1276305 (UMLS CUI-1)
    373808002 (SNOMED CT-1)
    CL Item
    Palliative - procedure intent  (P = palliativ)
    Palliative - procedure intent (qualifier value) (Code-1)
    C1285530 (UMLS CUI-1)
    363676003 (SNOMED CT-1)
    CL Item
    Diagnostic intent (D = diagnostisch)
    Intent For Diagnosis (Code-1)
    C0348026 (UMLS CUI-1)
    261004008 (SNOMED CT-1)
    CL Item
    unknown (unbekannt)
    Unknown (Code-1)
    C0439673 (UMLS CUI-1)
    261665006 (SNOMED CT-1)
    intraoperative Komplikationen
    Item
    Intraoperative Complication
    boolean
    must_have (Item-Info)
    C0021890 (UMLS CUI-1)
    10052620 (MedDRA-1)
    falls ja, welche
    Item
    Which Intraoperative Complication
    string
    C0021890 (UMLS CUI-1)
    10052620 (MedDRA-1)
    Free Text Format (Code-2)
    C2348713 (UMLS CUI-2)
    Back to the top of the page 

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