ID

42128

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 (2)
  1. 8/7/13 8/7/13 -
  2. 4/13/21 4/13/21 - Dr. rer. medic Philipp Neuhaus
Uploaded on

April 13, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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HIS medical history - prostate prostate cancer

German English

HIS

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

Admininstrative Daten

Patient name
Description

Patientenname

Data type

string

Alias
Code-1
Patient name (observable entity)
UMLS CUI-1
C1299487
SNOMED CT-1
371484003
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
Department
Description

Abteilung

Data type

string

Alias
UMLS CUI-1
C1704729
Aftercare Number
Description

Nachsorgepassnummer

Data type

integer

Alias
Code-1
Numbers
UMLS CUI-1
C0237753
SNOMED CT-1
410680006
LOINC-1
MTHU024869
Code-2
Aftercare
UMLS CUI-2
C0001758
SNOMED CT-2
413467001
Organspezifisch Prostata
Description

Organspezifisch Prostata

Cancer Diagnosis
Description

Tumordiagnose (ICD-10)

Data type

string

Alias
Item-Info
must_have
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
Item-Info
must_have
UMLS CUI-1
C2316983
SNOMED CT-1
432213005
Code-2
Tumor finding (finding)
UMLS CUI-2
C1274082
SNOMED CT-2
395557000
therapies
Description

Tatsächlich durchgeführte Therapie

Data type

integer

Alias
Code-1
Therapeutic procedure
UMLS CUI-1
C0087111
SNOMED CT-1
277132007
MedDRA-1
10053757
LOINC-1
MTHU008880
tissue collection consent
Description

tissue collection consent

informed consent for tissue collection
Description

Einwilligungsbogen vorhanden

Data type

boolean

Alias
Code-1
Tissue Collection
UMLS CUI-1
C0040278
Code-2
Informed consent obtained
UMLS CUI-2
C0514044
MedDRA-2
MTHU008888
not_coded
Description

Kommerzielle Verwertung

Data type

boolean

consent for tissue collection
Description

Einverständnis Probenarchivierung

Data type

boolean

Alias
Code-1
Defined Specimen Storage
UMLS CUI-1
C2985587
Code-2
consent
UMLS CUI-2
C1511481
MedDRA-2
MTHU035862
Tumorspezifische Daten
Description

Tumorspezifische Daten

Histologic Grade
Description

Histologie-Grad

Data type

integer

Alias
UMLS CUI-1
C0919553
SNOMED CT-1
371469007
Gleason-Score
Description

Gleason-Score

Data type

integer

Alias
Code-1
Gleason Score for Prostate Cancer
UMLS CUI-1
C0332326
SNOMED CT-1
106241006
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Primary Gleason Pattern
Description

Gleason-1

Data type

integer

Alias
UMLS CUI-1
C1273604
SNOMED CT-1
384994009
LOINC-1
MTHU020049
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Secondary Gleason Pattern
Description

Gleason-2

Data type

integer

Alias
UMLS CUI-1
C1273605
SNOMED CT-1
384995005
LOINC-1
MTHU020050
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Total Gleason Score for Prostate Cancer
Description

Gleason-Summe

Data type

integer

Alias
UMLS CUI-1
C1273607
SNOMED CT-1
384997002
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Digital Rectal Examination
Description

digitale rektale Untersuchung

Data type

integer

Alias
UMLS CUI-1
C1384593
SNOMED CT-1
410006001
ICD-9-CM-1
89.34
Prostate-Specific Antigen
Description

PSA (ng/ml)

Data type

string

Alias
Item-Info
ng/ml
UMLS CUI-1
C0138741
SNOMED CT-1
102687007
LOINC-1
MTHU001466
Date in time of PSA
Description

PSA-Datum

Data type

date

Alias
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Prostate Specific Antigen Measurement
UMLS CUI-2
C0201544
SNOMED CT-2
63476009
MedDRA-2
10050704
Scintigraphy
Description

Ganzkörperszintigramm

Data type

integer

Alias
Code-1
Radionuclide Imaging
UMLS CUI-1
C0034606
SNOMED CT-1
399019003
MedDRA-1
10061498
ICD-9-CM-1
92
Suspected
Description

suspekt?

Data type

integer

Alias
UMLS CUI-1
C0750491
SNOMED CT-1
415684004
Code-2
Radionuclide Imaging
UMLS CUI-2
C0034606
SNOMED CT-2
399019003
MedDRA-2
10061498
Location
Description

Lokalisation

Data type

string

Alias
UMLS CUI-1
C0450429
SNOMED CT-1
246267002
Code-2
Radionuclide Imaging
UMLS CUI-2
C0034606
SNOMED CT-2
399019003
MedDRA-2
10061498
Patientenbefragung
Description

Patientenbefragung

family history
Description

Vorerkrankungen in Familie

Data type

integer

Alias
Code-1
Family history
UMLS CUI-1
C0241889
SNOMED CT-1
57177007
Family members with Cancer
Description

Wieviele Angehörige in der Familie haben/hatten eine Tumorerkrankung?

Data type

integer

Alias
Code-1
Family Cancer History
UMLS CUI-1
C0260515
SNOMED CT-1
275937001
MedDRA-1
10062302
Family members with prostate cancer
Description

Wieviele davon ein Prostatakarzinom?

Data type

integer

Alias
Code-1
Family history of prostate cancer (situation)
UMLS CUI-1
C1532320
SNOMED CT-1
414205003
ICD-10-CM-1
Z80.42
ICD-9-CM-1
V16.42
Family members with other neoplasm
Description

Wie viele davon mit einer anderen Tumorart?

Data type

integer

Alias
Code-1
Family history of malignant neoplasm of other organs or systems
UMLS CUI-1
C0478620
ICD-10-CM-1
Z80.8
Request Nerve-Sparing Prostatectomy
Description

Nerverhalt erwünscht

Data type

boolean

Alias
Code-1
Nerve-Sparing Prostatectomy
UMLS CUI-1
C1514120
Code-2
Request
UMLS CUI-2
C1272683
SNOMED CT-2
385644000
Score
Description

Score

Score IIEF
Description

Score IIEF

Data type

string

Alias
Item-Info
must_have
Code-1
International index of erectile function score (observable entity)
UMLS CUI-1
C2959364
SNOMED CT-1
445930007
Score ICIQ
Description

Score ICIQ

Data type

string

Alias
Code-1
International consultation on incontinence questionnaire short form (assessment scale)
UMLS CUI-1
C2711268
SNOMED CT-1
442663009
Score IPSS
Description

Score IPSS

Data type

string

Alias
Code-1
International prostate symptom score (assessment scale)
UMLS CUI-1
C1998280
SNOMED CT-1
428433009
EORTC Fragen
Description

EORTC Fragen

International consultation on incontinence questionnaire short form (assessment scale)
Description

(Kontinenzbogen Frage 4)

Data type

integer

Alias
Code-1
International consultation on incontinence questionnaire short form (assessment scale)
UMLS CUI-1
C2711268
SNOMED CT-1
442663009
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale)
Description

(EQRTC QLQ-C30 Frage 29)

Data type

integer

Alias
Code-1
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale)
UMLS CUI-1
C0451149
SNOMED CT-1
273446001
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale)
Description

(EQRTC QLQ-C30 Frage 30)

Data type

integer

Alias
Code-1
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale)
UMLS CUI-1
C0451149
SNOMED CT-1
273446001
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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
Admininstrative Daten
Patientenname
Item
Patient name
string
Patient name (observable entity) (Code-1)
C1299487 (UMLS CUI-1)
371484003 (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)
Abteilung
Item
Department
string
C1704729 (UMLS CUI-1)
Nachsorgepassnummer
Item
Aftercare Number
integer
Numbers (Code-1)
C0237753 (UMLS CUI-1)
410680006 (SNOMED CT-1)
MTHU024869 (LOINC-1)
Aftercare (Code-2)
C0001758 (UMLS CUI-2)
413467001 (SNOMED CT-2)
Item Group
Organspezifisch Prostata
Tumordiagnose (ICD-10)
Item
Cancer Diagnosis
string
must_have (Item-Info)
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
must_have (Item-Info)
C2316983 (UMLS CUI-1)
432213005 (SNOMED CT-1)
Tumor finding (finding) (Code-2)
C1274082 (UMLS CUI-2)
395557000 (SNOMED CT-2)
Item
therapies
integer
Therapeutic procedure (Code-1)
C0087111 (UMLS CUI-1)
277132007 (SNOMED CT-1)
10053757 (MedDRA-1)
MTHU008880 (LOINC-1)
Tatsächlich durchgeführte Therapie
Code List
therapies
CL Item
Operative Surgical Procedures  (Operation)
C0543467 (UMLS CUI-1)
387713003 (SNOMED CT-1)
10042609 (MedDRA-1)
MTHU007597 (LOINC-1)
CL Item
Therapeutic radiology procedure  (Strahlentherapie)
C1522449 (UMLS CUI-1)
108290001 (SNOMED CT-1)
10037794 (MedDRA-1)
CL Item
Systemic Therapy (Systemische Therapie)
C1515119 (UMLS CUI-1)
CL Item
Other (Sonstiges)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Item Group
tissue collection consent
Einwilligungsbogen vorhanden
Item
informed consent for tissue collection
boolean
Tissue Collection (Code-1)
C0040278 (UMLS CUI-1)
Informed consent obtained (Code-2)
C0514044 (UMLS CUI-2)
MTHU008888 (MedDRA-2)
Kommerzielle Verwertung
Item
not_coded
boolean
Einverständnis Probenarchivierung
Item
consent for tissue collection
boolean
Defined Specimen Storage (Code-1)
C2985587 (UMLS CUI-1)
consent (Code-2)
C1511481 (UMLS CUI-2)
MTHU035862 (MedDRA-2)
Item Group
Tumorspezifische Daten
Item
Histologic Grade
integer
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
Histologie-Grad
Code List
Histologic Grade
CL Item
G1 grade  (G1)
G1 grade (finding) (Code-1)
C0475269 (UMLS CUI-1)
54102005 (SNOMED CT-1)
CL Item
G2 grade (G2)
G2 grade (finding) (Code-1)
C0475270 (UMLS CUI-1)
1663004 (SNOMED CT-1)
CL Item
G3 grade (G3)
G3 grade (finding) (Code-1)
C0475271 (UMLS CUI-1)
61026006 (SNOMED CT-1)
CL Item
Grade cannot be determined  (X)
Grade cannot be determined (finding) (Code-1)
C1273714 (UMLS CUI-1)
384741006 (SNOMED CT-1)
CL Item
Grade not designated (O)
Negation (Code-1)
C1518422 (UMLS CUI-1)
Designated (Code-2)
C1524084 (UMLS CUI-2)
CL Item
Low grade (Low grade)
Low grade (well to moderately differentiated) (finding) (Code-1)
C1273125 (UMLS CUI-1)
395529007 (SNOMED CT-1)
CL Item
High grade (High grade)
High grade (poorly differentiated to undifferentiated) (finding) (Code-1)
C1273126 (UMLS CUI-1)
395530002 (SNOMED CT-1)
Item
Gleason-Score
integer
Gleason Score for Prostate Cancer (Code-1)
C0332326 (UMLS CUI-1)
106241006 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-Score
Code List
Gleason-Score
CL Item
available (Angaben vorhanden)
Availability (Code-1)
C0470187 (UMLS CUI-1)
103328004 (SNOMED CT-1)
CL Item
Unspecified Gleason-Score (keine Angabe)
C0205370 (UMLS CUI-1)
10003008 (SNOMED CT-1)
Gleason-1
Item
Primary Gleason Pattern
integer
C1273604 (UMLS CUI-1)
384994009 (SNOMED CT-1)
MTHU020049 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-2
Item
Secondary Gleason Pattern
integer
C1273605 (UMLS CUI-1)
384995005 (SNOMED CT-1)
MTHU020050 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Gleason-Summe
Item
Total Gleason Score for Prostate Cancer
integer
C1273607 (UMLS CUI-1)
384997002 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Item
Digital Rectal Examination
integer
C1384593 (UMLS CUI-1)
410006001 (SNOMED CT-1)
89.34 (ICD-9-CM-1)
digitale rektale Untersuchung
Code List
Digital Rectal Examination
CL Item
Suspected (suspekt)
C0750491 (UMLS CUI-1)
415684004 (SNOMED CT-1)
CL Item
not suspected (nicht suspekt)
NOT suspected (qualifier value) (Code-1)
C1997218 (UMLS CUI-1)
428263003 (SNOMED CT-1)
CL Item
Unknown (unbekannt)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
PSA (ng/ml)
Item
Prostate-Specific Antigen
string
ng/ml (Item-Info)
C0138741 (UMLS CUI-1)
102687007 (SNOMED CT-1)
MTHU001466 (LOINC-1)
PSA-Datum
Item
Date in time of PSA
date
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Prostate Specific Antigen Measurement (Code-2)
C0201544 (UMLS CUI-2)
63476009 (SNOMED CT-2)
10050704 (MedDRA-2)
Item
Scintigraphy
integer
Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061498 (MedDRA-1)
92 (ICD-9-CM-1)
Ganzkörperszintigramm
Code List
Scintigraphy
CL Item
Yes (Ja)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
No (Nein)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Unknown (unbekannt)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
Item
Suspected
integer
C0750491 (UMLS CUI-1)
415684004 (SNOMED CT-1)
Radionuclide Imaging (Code-2)
C0034606 (UMLS CUI-2)
399019003 (SNOMED CT-2)
10061498 (MedDRA-2)
suspekt?
Code List
Suspected
CL Item
Yes (Ja)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
No (Nein)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Unknown (unbekannt)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
Lokalisation
Item
Location
string
C0450429 (UMLS CUI-1)
246267002 (SNOMED CT-1)
Radionuclide Imaging (Code-2)
C0034606 (UMLS CUI-2)
399019003 (SNOMED CT-2)
10061498 (MedDRA-2)
Item Group
Patientenbefragung
Item
family history
integer
Family history (Code-1)
C0241889 (UMLS CUI-1)
57177007 (SNOMED CT-1)
Vorerkrankungen in Familie
Code List
family history
CL Item
Yes (Vorerkrankung in der Familie)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
No (keine Vorerkrankung in der Familie)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Unknown (unbekannt)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
Wieviele Angehörige in der Familie haben/hatten eine Tumorerkrankung?
Item
Family members with Cancer
integer
Family Cancer History (Code-1)
C0260515 (UMLS CUI-1)
275937001 (SNOMED CT-1)
10062302 (MedDRA-1)
Wieviele davon ein Prostatakarzinom?
Item
Family members with prostate cancer
integer
Family history of prostate cancer (situation) (Code-1)
C1532320 (UMLS CUI-1)
414205003 (SNOMED CT-1)
Z80.42 (ICD-10-CM-1)
V16.42 (ICD-9-CM-1)
Wie viele davon mit einer anderen Tumorart?
Item
Family members with other neoplasm
integer
Family history of malignant neoplasm of other organs or systems (Code-1)
C0478620 (UMLS CUI-1)
Z80.8 (ICD-10-CM-1)
Nerverhalt erwünscht
Item
Request Nerve-Sparing Prostatectomy
boolean
Nerve-Sparing Prostatectomy (Code-1)
C1514120 (UMLS CUI-1)
Request (Code-2)
C1272683 (UMLS CUI-2)
385644000 (SNOMED CT-2)
Item Group
Score
Score IIEF
Item
Score IIEF
string
must_have (Item-Info)
International index of erectile function score (observable entity) (Code-1)
C2959364 (UMLS CUI-1)
445930007 (SNOMED CT-1)
Score ICIQ
Item
Score ICIQ
string
International consultation on incontinence questionnaire short form (assessment scale) (Code-1)
C2711268 (UMLS CUI-1)
442663009 (SNOMED CT-1)
Score IPSS
Item
Score IPSS
string
International prostate symptom score (assessment scale) (Code-1)
C1998280 (UMLS CUI-1)
428433009 (SNOMED CT-1)
Item Group
EORTC Fragen
(Kontinenzbogen Frage 4)
Item
International consultation on incontinence questionnaire short form (assessment scale)
integer
International consultation on incontinence questionnaire short form (assessment scale) (Code-1)
C2711268 (UMLS CUI-1)
442663009 (SNOMED CT-1)
(EQRTC QLQ-C30 Frage 29)
Item
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale)
integer
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale) (Code-1)
C0451149 (UMLS CUI-1)
273446001 (SNOMED CT-1)
(EQRTC QLQ-C30 Frage 30)
Item
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale)
integer
European Organization for Research and Treatment of Cancer - Quality of life questionnaire (assessment scale) (Code-1)
C0451149 (UMLS CUI-1)
273446001 (SNOMED CT-1)
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