HIS

1 forms

StudyEvent: HIS
1. HIS

Kopfzeile

Description

Kopfzeile

Date of Report

Description

Bericht vom:

Data type

date

Alias

Code-1: Date of Report

UMLS CUI-1: C1302584

SNOMED CT-1: 399651003

Physician

Description

Arztkürzel

Data type

string

Alias

Code-1: Physicians

UMLS CUI-1: C0031831

SNOMED CT-1: 112247003

LOINC-1: MTHU010489

Patientendaten

Description

Patientendaten

Patient name

Description

Patientenname

Data type

string

Alias

Code-1: Patient name (observable entity)

UMLS CUI-1: C1299487

SNOMED CT-1: 371484003

Patient date of birth

Description

Geburtsdatum

Data type

date

Alias

UMLS CUI-1: C0421451

SNOMED CT-1: 184099003

Case Identifier

Description

Fall-Nr.

Data type

string

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

Hospital

Description

Aufnahmeklinik

Data type

string

Alias

Code-1: Hospitals

UMLS CUI-1: C0019994

LOINC-1: MTHU002722

Admission date

Description

Aufnahmedatum

Data type

date

Alias

Code-1: Date of admission

UMLS CUI-1: C1302393

SNOMED CT-1: 399423000

LOINC-1: MTHU029790

Discharge date

Description

Entlassungsdatum

Data type

date

Alias

Code-1: Discharge date

UMLS CUI-1: C2361123

SNOMED CT-1: 442864001

LOINC-1: MTHU028123

Admission status

Description

Aufnahmeart

Data type

string

Alias

Code-1: Admission statuses (finding)

UMLS CUI-1: C0586002

SNOMED CT-1: 308277006

Ward

Description

Station

Data type

string

Alias

Code-1: Ward (environment)

UMLS CUI-1: C1305702

SNOMED CT-1: 225746001

OP-Personal

Description

OP-Personal

Anesthesiologist

Description

Anästhesie

Data type

string

Alias

Code-1: Anesthesiologist

UMLS CUI-1: C0334910

SNOMED CT-1: 88189002

Surgeon Staff

Description

OP-Team

Data type

string

Alias

Code-1: Surgeon.staff

UMLS CUI-1: C0552622

LOINC-1: MTHU002745

Weitere Angaben für Urologie-Ops

Description

Weitere Angaben für Urologie-Ops

Intraoperative

Description

Intraoperative

Specimen

Description

Histologische Präparate?

Data type

string

Alias

Code-1: Specimen

UMLS CUI-1: C0370003

SNOMED CT-1: 123038009

LOINC-1: MTHU010726

Length of surgical procedure

Description

OP-Dauer (min)

Data type

string

Alias

Code-1: Length of procedure (observable entity)

UMLS CUI-1: C1299418

SNOMED CT-1: 371767005

Code-2: Operative Surgical Procedures

UMLS CUI-2: C0543467

SNOMED CT-2: 387713003

MedDRA-2: 10042609

LOINC-2: MTHU007597

Volume Prostate

Description

Prostatavolumen (ccm)

Data type

string

Alias

Code-1: Volume

UMLS CUI-1: C0449468

SNOMED CT-1: 118565006

LOINC-1: MTHU003070

Code-2: Prostate

UMLS CUI-2: C0033572

SNOMED CT-2: 41216001

LOINC-2: MTHU004957

estimated blood loss

Description

Geschätzter Blutverlust (l)

Data type

string

Alias

Code-1: Surgical operation note estimated blood loss:Vol:Procedure dur:^Patient:Qn

UMLS CUI-1: C0488622

LOINC-1: 8717-1

Erythrocyte Transfusion

Description

Erythrozytenkonzentrate intra-OP (l)

Data type

string

Alias

Code-1: Erythrocyte Transfusion

UMLS CUI-1: C0086252

SNOMED CT-1: 116863004

Infusion

Description

Infusionsmenge

Data type

string

Alias

Code-1: Infusion procedures

UMLS CUI-1: C0574032

SNOMED CT-1: 36576007

MedDRA-1: 10060345

HL7 V3-1: _Infusion

Anastomosis, intact

Description

Anastomose dicht

Data type

boolean

Alias

Code-1: Anastomosis, intact (morphologic abnormality)

UMLS CUI-1: C1265704

SNOMED CT-1: 125215000

Yes

not_coded

Description

Kont. Gef. ?

Data type

string

Lesion of rectum

Description

Rektumläsion

Data type

boolean

Alias

Code-1: Lesion of rectum (finding)

UMLS CUI-1: C0577034

SNOMED CT-1: 300312006

MedDRA-1: 10054828

Yes

Obturator nerve lesion

Description

Nervus obturatorius Läsion

Data type

boolean

Alias

Code-1: Obturator nerve lesion (disorder)

UMLS CUI-1: C0574915

SNOMED CT-1: 298130005

MedDRA-1: 10065292

Yes

Intraoperative Complication

Description

andere Komplikation

Data type

boolean

Alias

UMLS CUI-1: C0021890

MedDRA-1: 10052620

Yes

signature physician

Description

Unterschrift Arzt

Data type

string

Alias

Code-1: Signature of responsible attending physician on file

UMLS CUI-1: C0807938

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HIS

1 forms

StudyEvent: HIS
1. HIS

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

Kopfzeile

Item Group

Kopfzeile

Bericht vom:

Item

Date of Report

date

Date of Report (Code-1)
C1302584 (UMLS CUI-1)
399651003 (SNOMED CT-1)

Arztkürzel

Item

Physician

string

Physicians (Code-1)
C0031831 (UMLS CUI-1)
112247003 (SNOMED CT-1)
MTHU010489 (LOINC-1)

Patientendaten

Item Group

Patientendaten

Patientenname

Item

Patient name

string

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

Geburtsdatum

Item

Patient date of birth

date

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

Fall-Nr.

Item

Case Identifier

string

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)

Aufnahmeklinik

Item

Hospital

string

Hospitals (Code-1)
C0019994 (UMLS CUI-1)
MTHU002722 (LOINC-1)

Aufnahmedatum

Item

Admission date

date

Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)

Entlassungsdatum

Item

Discharge date

date

Discharge date (Code-1)
C2361123 (UMLS CUI-1)
442864001 (SNOMED CT-1)
MTHU028123 (LOINC-1)

Aufnahmeart

Item

Admission status

string

Admission statuses (finding) (Code-1)
C0586002 (UMLS CUI-1)
308277006 (SNOMED CT-1)

Station

Item

Ward

string

Ward (environment) (Code-1)
C1305702 (UMLS CUI-1)
225746001 (SNOMED CT-1)

OP-Personal

Item Group

OP-Personal

Anästhesie

Item

Anesthesiologist

string

Anesthesiologist (Code-1)
C0334910 (UMLS CUI-1)
88189002 (SNOMED CT-1)

OP-Team

Item

Surgeon Staff

string

Surgeon.staff (Code-1)
C0552622 (UMLS CUI-1)
MTHU002745 (LOINC-1)

Weitere Angaben für Urologie-Ops

Item Group

Weitere Angaben für Urologie-Ops

Intraoperativ

Item Group

Intraoperative

Histologische Präparate?

Item

Specimen

string

Specimen (Code-1)
C0370003 (UMLS CUI-1)
123038009 (SNOMED CT-1)
MTHU010726 (LOINC-1)

OP-Dauer (min)

Item

Length of surgical procedure

string

Length of procedure (observable entity) (Code-1)
C1299418 (UMLS CUI-1)
371767005 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)

Prostatavolumen (ccm)

Item

Volume Prostate

string

Volume (Code-1)
C0449468 (UMLS CUI-1)
118565006 (SNOMED CT-1)
MTHU003070 (LOINC-1)
Prostate (Code-2)
C0033572 (UMLS CUI-2)
41216001 (SNOMED CT-2)
MTHU004957 (LOINC-2)

Geschätzter Blutverlust (l)

Item

estimated blood loss

string

Surgical operation note estimated blood loss:Vol:Procedure dur:^Patient:Qn (Code-1)
C0488622 (UMLS CUI-1)
8717-1 (LOINC-1)

Erythrozytenkonzentrate intra-OP (l)

Item

Erythrocyte Transfusion

string

Erythrocyte Transfusion (Code-1)
C0086252 (UMLS CUI-1)
116863004 (SNOMED CT-1)

Infusionsmenge

Item

Infusion

string

Infusion procedures (Code-1)
C0574032 (UMLS CUI-1)
36576007 (SNOMED CT-1)
10060345 (MedDRA-1)
_Infusion (HL7 V3-1)

Anastomose dicht

Item

Anastomosis, intact

boolean

Anastomosis, intact (morphologic abnormality) (Code-1)
C1265704 (UMLS CUI-1)
125215000 (SNOMED CT-1)

Kont. Gef. ?

Item

not_coded

string

Rektumläsion

Item

Lesion of rectum

boolean

Lesion of rectum (finding) (Code-1)
C0577034 (UMLS CUI-1)
300312006 (SNOMED CT-1)
10054828 (MedDRA-1)

Nervus obturatorius Läsion

Item

Obturator nerve lesion

boolean

Obturator nerve lesion (disorder) (Code-1)
C0574915 (UMLS CUI-1)
298130005 (SNOMED CT-1)
10065292 (MedDRA-1)

andere Komplikation

Item

Intraoperative Complication

boolean

C0021890 (UMLS CUI-1)
10052620 (MedDRA-1)

Unterschrift Arzt

Item

signature physician

string

Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)

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