ID

42134

Beskrivning

HIS form ORBIS. with friendly permission form urology (Prof. Semjonow) and medical informatics department (Dr. Breil)

Nyckelord

Versioner (2)
  1. 2013-08-07 2013-08-07 -
  2. 2021-04-13 2021-04-13 - Dr. rer. medic Philipp Neuhaus
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13 april 2021

DOI

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

Tysk Engelsk

HIS

1 Formulär  
  1. StudyEvent: HIS
    1. HIS
Kopfzeile
Beskrivning

Kopfzeile

Date of Report
Beskrivning

Bericht vom:

Datatyp

date

Alias
Code-1
Date of Report
UMLS CUI-1
C1302584
SNOMED CT-1
399651003
Physician
Beskrivning

Arztkürzel

Datatyp

string

Alias
Code-1
Physicians
UMLS CUI-1
C0031831
SNOMED CT-1
112247003
LOINC-1
MTHU010489
Patientendaten
Beskrivning

Patientendaten

Patient name
Beskrivning

Patientenname

Datatyp

string

Alias
Code-1
Patient name (observable entity)
UMLS CUI-1
C1299487
SNOMED CT-1
371484003
Patient date of birth
Beskrivning

Geburtsdatum

Datatyp

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Case Identifier
Beskrivning

Fall-Nr.

Datatyp

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
Beskrivning

Aufnahmeklinik

Datatyp

string

Alias
Code-1
Hospitals
UMLS CUI-1
C0019994
LOINC-1
MTHU002722
Admission date
Beskrivning

Aufnahmedatum

Datatyp

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Discharge date
Beskrivning

Entlassungsdatum

Datatyp

date

Alias
Code-1
Discharge date
UMLS CUI-1
C2361123
SNOMED CT-1
442864001
LOINC-1
MTHU028123
Admission status
Beskrivning

Aufnahmeart

Datatyp

string

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

Station

Datatyp

string

Alias
Code-1
Ward (environment)
UMLS CUI-1
C1305702
SNOMED CT-1
225746001
OP-Personal
Beskrivning

OP-Personal

Anesthesiologist
Beskrivning

Anästhesie

Datatyp

string

Alias
Code-1
Anesthesiologist
UMLS CUI-1
C0334910
SNOMED CT-1
88189002
Surgeon Staff
Beskrivning

OP-Team

Datatyp

string

Alias
Code-1
Surgeon.staff
UMLS CUI-1
C0552622
LOINC-1
MTHU002745
Weitere Angaben für Urologie-Ops
Beskrivning

Weitere Angaben für Urologie-Ops

Intraoperative
Beskrivning

Intraoperative

Specimen
Beskrivning

Histologische Präparate?

Datatyp

string

Alias
Code-1
Specimen
UMLS CUI-1
C0370003
SNOMED CT-1
123038009
LOINC-1
MTHU010726
Length of surgical procedure
Beskrivning

OP-Dauer (min)

Datatyp

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
Beskrivning

Prostatavolumen (ccm)

Datatyp

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
Beskrivning

Geschätzter Blutverlust (l)

Datatyp

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
Beskrivning

Erythrozytenkonzentrate intra-OP (l)

Datatyp

string

Alias
Code-1
Erythrocyte Transfusion
UMLS CUI-1
C0086252
SNOMED CT-1
116863004
Infusion
Beskrivning

Infusionsmenge

Datatyp

string

Alias
Code-1
Infusion procedures
UMLS CUI-1
C0574032
SNOMED CT-1
36576007
MedDRA-1
10060345
HL7 V3-1
_Infusion
Anastomosis, intact
Beskrivning

Anastomose dicht

Datatyp

boolean

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

Kont. Gef. ?

Datatyp

string

Lesion of rectum
Beskrivning

Rektumläsion

Datatyp

boolean

Alias
Code-1
Lesion of rectum (finding)
UMLS CUI-1
C0577034
SNOMED CT-1
300312006
MedDRA-1
10054828
Obturator nerve lesion
Beskrivning

Nervus obturatorius Läsion

Datatyp

boolean

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

andere Komplikation

Datatyp

boolean

Alias
UMLS CUI-1
C0021890
MedDRA-1
10052620
signature physician
Beskrivning

Unterschrift Arzt

Datatyp

string

Alias
Code-1
Signature of responsible attending physician on file
UMLS CUI-1
C0807938
Tillbaka till toppen

Similar models

HIS

1 Formulär
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
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)
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)
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)
Item Group
Weitere Angaben für Urologie-Ops
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)
Tillbaka till toppen 

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