ID

42219

Description

HIS form ORBIS. with friendly permission form gynecology (Dr. Tio) and medical informatics department (Dr. Breil)

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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Creative Commons BY-NC 3.0 Legacy
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HIS course of treatment - tumortherapy breast cancer

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
Patientenaufkleber groß
Description

Patientenaufkleber groß

Patient Identification Number
Description

PatientenID

Data type

integer

Alias
Code-1
Patients
UMLS CUI-1
C0030705
SNOMED CT-1
116154003
Code-2
Identification number
UMLS CUI-2
C1300638
SNOMED CT-2
396278008
Patient sex
Description

Geschlecht

Data type

string

Alias
UMLS CUI-1
C0150831
SNOMED CT-1
184100006
Patient surname
Description

Nachname

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 date of birth
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Tumorverlaufsbogen
Description

Tumorverlaufsbogen

patient name
Description

Patientenname

Data type

string

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

Geburtsdatum Patient

Data type

date

Alias
Code-1
Patient date of birth
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
responsible person
Description

Erhoben von

Data type

string

Alias
Code-1
Responsible Person
UMLS CUI-1
C1273518
SNOMED CT-1
394851003
date of collection
Description

Erhoben am

Data type

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Collection
UMLS CUI-2
C1516698
Gynecologist
Description

Frauenarzt/-ärztin

Data type

string

Alias
Code-1
Gynecologist
UMLS CUI-1
C0237419
SNOMED CT-1
83685006
HL7 V3-1
207VG0400X
Primary Care Physician
Description

Hausarzt/-ärztin

Data type

string

Alias
Code-1
Primary Care Physicians
UMLS CUI-1
C0033131
SNOMED CT-1
446050000
Chemotherapy cycle
Description

Zyklus

Data type

string

Alias
Code-1
Chemotherapy cycle (procedure)
UMLS CUI-1
C1302181
SNOMED CT-1
399042005
Code-2
Current Therapy
UMLS CUI-2
C2827774
Clinical Trials
Description

Studie

Data type

boolean

Alias
Code-1
Clinical Trials
UMLS CUI-1
C0008976
SNOMED CT-1
110465008
Diagnosis
Description

Diagnose

Data type

string

Alias
Code-1
Diagnosis
UMLS CUI-1
C0011900
SNOMED CT-1
439401001
LOINC-1
MTHU008876
Progression of disease
Description

Verlauf der Erkrankung

Data type

string

Alias
Code-1
Disease Progression
UMLS CUI-1
C0242656
SNOMED CT-1
246453008
MedDRA-1
10061818
LOINC-1
MTHU039942
Progression of therapy
Description

Verlauf der akt. Therapie

Data type

string

Alias
Code-1
Progression (attribute)
UMLS CUI-1
C0449258
SNOMED CT-1
246450006
Code-2
Therapeutic procedure
UMLS CUI-2
C0087111
SNOMED CT-2
277132007
MedDRA-2
10053757
LOINC-2
MTHU008880
Stage
Description

Erkrankungsstadium

Data type

integer

Alias
Code-1
Stage
UMLS CUI-1
C1300072
SNOMED CT-1
371508000
comment metastatic neoplasm
Description

Bemerkung metastasiert

Data type

string

Alias
Code-1
Metastatic Neoplasm
UMLS CUI-1
C2939420
MedDRA-1
10062194
ICD-10-CM-1
C79.9
Code-2
Comment
UMLS CUI-2
C0947611
LOINC-2
MTHU013736
Tumor Biology
Description

Tumor Biology

Hormone Receptor
Description

Hormone Receptor

Estrogen Receptor
Description

Östrogen (ER)

Data type

integer

Alias
Code-Info
extended_coding
Code-1
Status of estrogen receptors of neoplasm (observable entity)
UMLS CUI-1
C2919271
SNOMED CT-1
445028008
progesterone receptor
Description

Progesteron (PR)

Data type

integer

Alias
Code-Info
extended_coding
Code-1
Status of progesterone receptors of neoplasm (observable entity)
UMLS CUI-1
C2919590
SNOMED CT-1
445029000
Her-2/neu
Description

HER2-Status

Data type

integer

Alias
Item-Info
Her-2/neu
Code-1
Her2/Neu Status
UMLS CUI-1
C1512413
Diagnostic procedure
Description

Diagnostic procedure

Echocardiography
Description

Echo aktuell und unauffällig

Data type

integer

Alias
Code-1
Echocardiography
UMLS CUI-1
C0013516
SNOMED CT-1
40701008
MedDRA-1
10014113
ICD-9-CM-1
88.72
comment sonography
Description

Bemerkung Echo

Data type

string

Alias
Code-1
Echocardiography
UMLS CUI-1
C0013516
SNOMED CT-1
40701008
MedDRA-1
10014113
Code-2
Comment
UMLS CUI-2
C0947611
LOINC-2
MTHU013736
disease stage
Description

Staging aktuell

Data type

integer

Alias
Code-1
disease stage
UMLS CUI-1
C0699749
comment staging
Description

Bemerkung Staging

Data type

string

Alias
Code-1
disease stage
UMLS CUI-1
C0699749
Code-2
Comment
UMLS CUI-2
C0947611
LOINC-2
MTHU013736
Normal laboratory finding (navigational concept)
Description

unauffällig Laborwerte

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Normal laboratory finding (navigational concept)
UMLS CUI-1
C0586624
SNOMED CT-1
309157004
Abnormal Laboratory Test Result
Description

auffällige Laborwerte

Data type

boolean

Alias
Code-Info
changed_datatype
Code-1
Abnormal Laboratory Test Result
UMLS CUI-1
C0438215
SNOMED CT-1
165346000
MedDRA-1
10023547
Laboratory not indicated
Description

Laboruntersuchung nicht indiziert

Data type

boolean

Alias
Code-Info
merged_coding, changed_datatype
Code-1
Not indicated (qualifier value)
UMLS CUI-1
C1444655
SNOMED CT-1
410534003
Code-2
Laboratory Procedures
UMLS CUI-2
C0022885
SNOMED CT-2
108252007
MedDRA-2
10059938
comment laboratory
Description

Bemerkung Labor

Data type

string

Alias
Code-1
Laboratory Procedures
UMLS CUI-1
C0022885
SNOMED CT-1
108252007
MedDRA-1
10059938
Code-2
Comment
UMLS CUI-2
C0947611
LOINC-2
MTHU013736
Urinalysis dipstick test
Description

U-Stix unauffällig

Data type

integer

Alias
Code-1
Urinalysis dipstick test status
UMLS CUI-1
C1545794
LOINC-1
MTHU017933
comment urinanlysis
Description

Bemerkung U-Stix

Data type

string

Alias
Code-1
Urinalysis dipstick test status
UMLS CUI-1
C1545794
LOINC-1
MTHU017933
Code-2
Comment
UMLS CUI-2
C0947611
LOINC-2
MTHU013736
Medical History
Description

Medical History

Karnofsky Performance Status
Description

Karnofsky Index

Data type

integer

Alias
Code-1
Karnofsky Performance Status
UMLS CUI-1
C0206065
SNOMED CT-1
273546003
MedDRA-1
10054755
ECOG performance status grade
Description

ECOG

Data type

integer

Alias
UMLS CUI-1
C1632812
Complaints
Description

Patientin hat aktuell Beschwerden

Data type

boolean

Alias
Code-1
Chief complaint (finding)
UMLS CUI-1
C0277786
SNOMED CT-1
409586006
LOINC-1
MTHU001077
Complaints
Description

Beschwerden

Data type

string

Alias
Code-1
Chief complaint (finding)
UMLS CUI-1
C0277786
SNOMED CT-1
409586006
LOINC-1
MTHU001077
Code-2
Free Text Format
UMLS CUI-2
C2348713
Menstruation Disturbances
Description

Patientin hatte im letzten Zyklus Beschwerden

Data type

boolean

Alias
Code-1
Menstruation Disturbances
UMLS CUI-1
C0025345
SNOMED CT-1
289896006
MedDRA-1
10027327
Symptoms
Description

Art der Beschwerden

Data type

string

Alias
Code-1
Symptoms
UMLS CUI-1
C1457887
LOINC-1
MTHU021540
ICD-9-CM-1
780-789,99
Symptom severity level
Description

Grad der Beschwerden

Data type

integer

Alias
Code-1
Symptom severity level (observable entity)
UMLS CUI-1
C1319166
SNOMED CT-1
162465004
LOINC-1
MTHU038913
Therapy
Description

Therapy

intravenous via Portacath
Description

Applikation komplikationslos via Port

Data type

boolean

Alias
Code-1
Intravenous Route of Drug Administration
UMLS CUI-1
C1522726
SNOMED CT-1
47625008
HL7 V3-1
_IntravenousRoute
Code-2
Portacath
UMLS CUI-2
C0935727
Intravenous via Venous cannula
Description

Applikation komplikationslos via PVK

Data type

boolean

Alias
Code-1
Intravenous Route of Drug Administration
UMLS CUI-1
C1522726
SNOMED CT-1
47625008
HL7 V3-1
_IntravenousRoute
Code-2
Venous cannula (physical object)
UMLS CUI-2
C0179583
SNOMED CT-2
258621005
chemotherapy
Description

Chemotherapie appliziert

Data type

boolean

Alias
Code-1
Chemotherapy Regimen
UMLS CUI-1
C0392920
SNOMED CT-1
69960004
MedDRA-1
10061758
chemotherapy
Description

Chemotherapie

Data type

string

Alias
Code-1
Chemotherapy Regimen
UMLS CUI-1
C0392920
SNOMED CT-1
69960004
MedDRA-1
10061758
Code-2
Free Text Format
UMLS CUI-2
C2348713
Diphosphonates
Description

Bisphophonate appliziert

Data type

boolean

Alias
Code-1
Diphosphonates
UMLS CUI-1
C0012544
SNOMED CT-1
372907000
Diphosphonates
Description

Bisphophonate

Data type

string

Alias
Code-1
Diphosphonates
UMLS CUI-1
C0012544
SNOMED CT-1
372907000
Code-2
Free Text Format
UMLS CUI-2
C2348713
Endocrine Therapy
Description

Endokrine Therapie eingenommen

Data type

boolean

Alias
UMLS CUI-1
C0279025
SNOMED CT-1
169413002
MedDRA-1
10065646
Endocrine Therapy
Description

Endokrine Therapie

Data type

string

Alias
UMLS CUI-1
C0279025
SNOMED CT-1
169413002
MedDRA-1
10065646
Code-2
Free Text Format
UMLS CUI-2
C2348713
Drugs
Description

Aktuelle Medikation

Data type

string

Alias
Code-1
Pharmaceutical Preparations
UMLS CUI-1
C0013227
SNOMED CT-1
410942007
Drug Prescriptions
Description

Drug Prescriptions

Antiemetics
Description

Antiemese

Data type

integer

Alias
Code-Info
changed_datatype
Code-1
Antiemetics
UMLS CUI-1
C0003297
SNOMED CT-1
372764000
Mucositis management
Description

Mucositisprophylaxe

Data type

integer

Alias
Code-Info
changed_datatype
Code-1
Mucositis management
UMLS CUI-1
C0279839
other drugs
Description

Sonstige

Data type

integer

Alias
Code-Info
changed_datatype
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Code-2
Pharmaceutical Preparations
UMLS CUI-2
C0013227
SNOMED CT-2
410942007
next chemotherapy cycle
Description

next chemotherapy cycle

date next chemotherapy cycle
Description

Datum und Uhrzeit Zyklus

Data type

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Code-2
Chemotherapy cycle (procedure)
UMLS CUI-2
C1302181
SNOMED CT-2
399042005
Code-3
Next
UMLS CUI-3
CL414352
medical imaging
Description

Bildgebung

Data type

string

Alias
Code-1
Imaging, Medical
UMLS CUI-1
C0025086
Code-2
Free Text Format
UMLS CUI-2
C2348713
others
Description

Sonstiges

Data type

string

Alias
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Signature
Description

Unterschrift

Data type

string

Alias
Code-1
Signature of responsible attending physician on file
UMLS CUI-1
C0807938
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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
Patientenaufkleber groß
PatientenID
Item
Patient Identification Number
integer
Patients (Code-1)
C0030705 (UMLS CUI-1)
116154003 (SNOMED CT-1)
Identification number (Code-2)
C1300638 (UMLS CUI-2)
396278008 (SNOMED CT-2)
Geschlecht
Item
Patient sex
string
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
Nachname
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)
Geburtsdatum
Item
Patient date of birth
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Item Group
Tumorverlaufsbogen
Patientenname
Item
patient name
string
Patient name (observable entity) (Code-1)
C1299487 (UMLS CUI-1)
371484003 (SNOMED CT-1)
Geburtsdatum Patient
Item
Birth date
date
Patient date of birth (Code-1)
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Erhoben von