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

Patientenidentifikationsnummer
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
Geschlecht Patient
Description

Geschlecht

Data type

string

Alias
UMLS CUI-1
C0150831
SNOMED CT-1
184100006
Patienten-Nachname
Description

Nachname

Data type

string

Alias
UMLS CUI-1
C0421448
SNOMED CT-1
184096005
Patienten-Vorname
Description

Vorname

Data type

string

Alias
UMLS CUI-1
C0421447
SNOMED CT-1
184095009
Patienten-Geburtsdatum
Description

Geburtsdatum

Data type

date

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

Tumorverlaufsbogen

Patientenname
Description

Patientenname

Data type

string

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

Geburtsdatum Patient

Data type

date

Alias
Code-1
Patient date of birth
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
verantwortliche Person
Description

Erhoben von

Data type

string

Alias
Code-1
Responsible Person
UMLS CUI-1
C1273518
SNOMED CT-1
394851003
Datum der Erhebung
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
Frauenfacharzt
Description

Frauenarzt/-ärztin

Data type

string

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

Hausarzt/-ärztin

Data type

string

Alias
Code-1
Primary Care Physicians
UMLS CUI-1
C0033131
SNOMED CT-1
446050000
Chemotherapiezyklus
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
Studie
Description

Studie

Data type

boolean

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

Diagnose

Data type

string

Alias
Code-1
Diagnosis
UMLS CUI-1
C0011900
SNOMED CT-1
439401001
LOINC-1
MTHU008876
Verlauf der Erkrankung
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
Verlauf der Therapie
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
Stadium
Description

Erkrankungsstadium

Data type

integer

Alias
Code-1
Stage
UMLS CUI-1
C1300072
SNOMED CT-1
371508000
Bemerkung metastasiert
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
Tumorbiologie
Description

Tumorbiologie

Hormonrezeptoren
Description

Hormonrezeptoren

Östrogen-Rezeptor
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
Progesteron-Rezeptor
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
Diagnostik
Description

Diagnostik

Echokardiographie
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
Bemerkung Sonographie
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
Staging
Description

Staging aktuell

Data type

integer

Alias
Code-1
disease stage
UMLS CUI-1
C0699749
Bemerkung 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
unauffällig Laborwerte
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
auffällige Laborwerte
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
Laboruntersuchung nicht indiziert
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
Bemerkung Labor
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
Urinstick Test
Description

U-Stix unauffällig

Data type

integer

Alias
Code-1
Urinalysis dipstick test status
UMLS CUI-1
C1545794
LOINC-1
MTHU017933
Bemerkung Urinuntersuchung
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
Anamnese
Description

Anamnese

Karnofsky Index
Description

Karnofsky Index

Data type

integer

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

ECOG

Data type

integer

Alias
UMLS CUI-1
C1632812
Beschwerden
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
Beschwerden
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
Menstuationsbeschwerden
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
Symptome
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
Grad der Beschwerden
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
Therapie
Description

Therapie

intravenös via Port
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
intravenös via PVK
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
Chemotherapie
Description

Chemotherapie appliziert

Data type

boolean

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

Bisphophonate appliziert

Data type

boolean

Alias
Code-1
Diphosphonates
UMLS CUI-1
C0012544
SNOMED CT-1
372907000
Bisphosphonate
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
Hormon- / endokrine Therapie
Description

Endokrine Therapie eingenommen

Data type

boolean

Alias
UMLS CUI-1
C0279025
SNOMED CT-1
169413002
MedDRA-1
10065646
Hormon- / endokrine Therapie
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
Medikamente
Description

Aktuelle Medikation

Data type

string

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

Rezepte

Antiemetika
Description

Antiemese

Data type

integer

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

Mucositisprophylaxe

Data type

integer

Alias
Code-Info
changed_datatype
Code-1
Mucositis management
UMLS CUI-1
C0279839
andere Medikamente
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
nächster Chemotherapiezyklus
Description

nächster Chemotherapiezyklus

Datum nächster Chemotherapie Zyklus
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
Bildgebung
Description

Bildgebung

Data type

string

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

Sonstiges

Data type

string

Alias
Code-1
Other
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Unterschrift
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
Patientenidentifikationsnummer
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
Geschlecht Patient
string
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
Nachname
Item
Patienten-Nachname
string
C0421448 (UMLS CUI-1)
184096005 (SNOMED CT-1)
Vorname
Item
Patienten-Vorname
string
C0421447 (UMLS CUI-1)
184095009 (SNOMED CT-1)
Geburtsdatum
Item
Patienten-Geburtsdatum
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Item Group
Tumorverlaufsbogen
Patientenname
Item
Patientenname
string
Patient name (observable entity) (Code-1)
C1299487 (UMLS CUI-1)
371484003 (SNOMED CT-1)
Geburtsdatum Patient
Item
Geburtstag
date
Patient date of birth (Code-1)
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Erhoben von
Item
verantwortliche Person
string
Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
Erhoben am
Item
Datum der Erhebung
date
Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Collection (Code-2)
C1516698 (UMLS CUI-2)
Frauenarzt/-ärztin
Item
Frauenfacharzt
string
Gynecologist (Code-1)
C0237419 (UMLS CUI-1)
83685006 (SNOMED CT-1)
207VG0400X (HL7 V3-1)
Hausarzt/-ärztin
Item
Hausarzt
string
Primary Care Physicians (Code-1)
C0033131 (UMLS CUI-1)
446050000 (SNOMED CT-1)
Zyklus
Item
Chemotherapiezyklus
string
Chemotherapy cycle (procedure) (Code-1)
C1302181 (UMLS CUI-1)
399042005 (SNOMED CT-1)
Current Therapy (Code-2)
C2827774 (UMLS CUI-2)
Studie
Item
Studie
boolean
Clinical Trials (Code-1)
C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)
Diagnose
Item
Diagnose
string
Diagnosis (Code-1)
C0011900 (UMLS CUI-1)
439401001 (SNOMED CT-1)
MTHU008876 (LOINC-1)
Verlauf der Erkrankung
Item
Verlauf der Erkrankung
string
Disease Progression (Code-1)
C0242656 (UMLS CUI-1)
246453008 (SNOMED CT-1)
10061818 (MedDRA-1)
MTHU039942 (LOINC-1)
Verlauf der akt. Therapie
Item
Verlauf der Therapie
string
Progression (attribute) (Code-1)
C0449258 (UMLS CUI-1)
246450006 (SNOMED CT-1)
Therapeutic procedure (Code-2)
C0087111 (UMLS CUI-2)
277132007 (SNOMED CT-2)
10053757 (MedDRA-2)
MTHU008880 (LOINC-2)
Item
Stadium
integer
Stage (Code-1)
C1300072 (UMLS CUI-1)
371508000 (SNOMED CT-1)
Erkrankungsstadium
Code List
Stadium
CL Item
Primärtumor (Primärtumor)
Primary Malignant Neoplasm (Code-1)
C1306459 (UMLS CUI-1)
372087000 (SNOMED CT-1)
CL Item
lokal-fortgeschritten (lokal-fortgeschritten)
Locally Advanced Malignant Neoplasm (Code-1)
C0677984 (UMLS CUI-1)
CL Item
lokal-rezidiviert (lokal-rezidiviert)
Neoplasm Recurrence, Local (Code-1)
C0027643 (UMLS CUI-1)
CL Item
metastasiert (metastasiert)
Metastatic Neoplasm (Code-1)
C2939420 (UMLS CUI-1)
10062194 (MedDRA-1)
C79.9 (ICD-10-CM-1)
Bemerkung metastasiert
Item
Bemerkung metastasiert
string
Metastatic Neoplasm (Code-1)
C2939420 (UMLS CUI-1)
10062194 (MedDRA-1)
C79.9 (ICD-10-CM-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
Item Group
Tumorbiologie
Item Group
Hormonrezeptoren
Item
Östrogen-Rezeptor
integer
extended_coding (Code-Info)
Status of estrogen receptors of neoplasm (observable entity) (Code-1)
C2919271 (UMLS CUI-1)
445028008 (SNOMED CT-1)
Östrogen (ER)
Code List
Östrogen-Rezeptor
CL Item
positiv (positiv)
extended_coding (Code-Info)
Estrogen receptor positive tumor (disorder) (Code-1)
C1562312 (UMLS CUI-1)
416053008 (SNOMED CT-1)
CL Item
negativ (negativ)
extended_coding (Code-Info)
Estrogen receptor negative neoplasm (disorder) (Code-1)
C2584629 (UMLS CUI-1)
441117001 (SNOMED CT-1)
CL Item
nicht bestätigt (nicht best.)
Approval (Code-1)
C0205540 (UMLS CUI-1)
9571008 (SNOMED CT-1)
Negation (Code-2)
C1518423 (UMLS CUI-2)
CL Item
only_in_connection with PR (only_in_connection with PR)
Item
Progesteron-Rezeptor
integer
extended_coding (Code-Info)
Status of progesterone receptors of neoplasm (observable entity) (Code-1)
C2919590 (UMLS CUI-1)
445029000 (SNOMED CT-1)
Progesteron (PR)
Code List
Progesteron-Rezeptor
CL Item
positiv (positiv)
extended_coding (Code-Info)
Progesterone receptor positive tumor (disorder) (Code-1)
C1562928 (UMLS CUI-1)
416561008 (SNOMED CT-1)
CL Item
negativ (negativ)
extended_coding (Code-Info)
Progesterone receptor negative neoplasm (disorder) (Code-1)
C2584628 (UMLS CUI-1)
441118006 (SNOMED CT-1)
CL Item
nicht bestätigt (nicht best.)
Approval (Code-1)
C0205540 (UMLS CUI-1)
9571008 (SNOMED CT-1)
Negation (Code-2)
C1518423 (UMLS CUI-2)
CL Item
only_in_connection with ER (only_in_connection with ER)
Item
Her-2/neu
integer
Her-2/neu (Item-Info)
Her2/Neu Status (Code-1)
C1512413 (UMLS CUI-1)
HER2-Status
Code List
Her-2/neu
CL Item
positive (pos)
positiv (Item-Info)
HER2-positive carcinoma of breast (disorder) (Code-1)
C1960398 (UMLS CUI-1)
427685000 (SNOMED CT-1)
CL Item
negative (neg)
negativ (Item-Info)
HER2-negative breast cancer (Code-1)
CL412283 (UMLS CUI-1)
CL Item
nicht bestätigt (nicht best.)
Approval (Code-1)
C0205540 (UMLS CUI-1)
9571008 (SNOMED CT-1)
Negation (Code-2)
C1518423 (UMLS CUI-2)
Item Group
Diagnostik
Item
Echokardiographie
integer
Echocardiography (Code-1)
C0013516 (UMLS CUI-1)
40701008 (SNOMED CT-1)
10014113 (MedDRA-1)
88.72 (ICD-9-CM-1)
Echo aktuell und unauffällig
Code List
Echokardiographie
CL Item
unauffällig (ja)
Echography normal (Code-1)
C0853525 (UMLS CUI-1)
10014124 (MedDRA-1)
CL Item
auffällig (nein)
Echography abnormal (Code-1)
C0853527 (UMLS CUI-1)
10014123 (MedDRA-1)
CL Item
nicht indiziert (nicht indiziert)
Not indicated (qualifier value) (Code-1)
C1444655 (UMLS CUI-1)
410534003 (SNOMED CT-1)
Bemerkung Echo
Item
Bemerkung Sonographie
string
Echocardiography (Code-1)
C0013516 (UMLS CUI-1)
40701008 (SNOMED CT-1)
10014113 (MedDRA-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
Item
Staging
integer
disease stage (Code-1)
C0699749 (UMLS CUI-1)
Staging aktuell
Code List
Staging
CL Item
Ja (ja)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
Nein (nein)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
nicht indiziert (nicht indiziert)
Not indicated (qualifier value) (Code-1)
C1444655 (UMLS CUI-1)
410534003 (SNOMED CT-1)
Bemerkung Staging
Item
Bemerkung staging
string
disease stage (Code-1)
C0699749 (UMLS CUI-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
unauffällig Laborwerte
Item
unauffällig Laborwerte
boolean
changed_datatype (Code-Info)
Normal laboratory finding (navigational concept) (Code-1)
C0586624 (UMLS CUI-1)
309157004 (SNOMED CT-1)
auffällige Laborwerte
Item
auffällige Laborwerte
boolean
changed_datatype (Code-Info)
Abnormal Laboratory Test Result (Code-1)
C0438215 (UMLS CUI-1)
165346000 (SNOMED CT-1)
10023547 (MedDRA-1)
Laboruntersuchung nicht indiziert
Item
Laboruntersuchung nicht indiziert
boolean
merged_coding, changed_datatype (Code-Info)
Not indicated (qualifier value) (Code-1)
C1444655 (UMLS CUI-1)
410534003 (SNOMED CT-1)
Laboratory Procedures (Code-2)
C0022885 (UMLS CUI-2)
108252007 (SNOMED CT-2)
10059938 (MedDRA-2)
Bemerkung Labor
Item
Bemerkung Labor
string
Laboratory Procedures (Code-1)
C0022885 (UMLS CUI-1)
108252007 (SNOMED CT-1)
10059938 (MedDRA-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
Item
Urinstick Test
integer
Urinalysis dipstick test status (Code-1)
C1545794 (UMLS CUI-1)
MTHU017933 (LOINC-1)
U-Stix unauffällig
Code List
Urinstick Test
CL Item
unauffällig (ja)
Urinalysis = no abnormality (finding) (Code-1)
C0438141 (UMLS CUI-1)
171250001 (SNOMED CT-1)
10061578 (MedDRA-1)
CL Item
auffällig (nein)
Abnormal Urine Test Result (Code-1)
C0438142 (UMLS CUI-1)
171251002 (SNOMED CT-1)
10062226 (MedDRA-1)
CL Item
nicht indiziert (nicht indiziert)
Not indicated (qualifier value) (Code-1)
C1444655 (UMLS CUI-1)
410534003 (SNOMED CT-1)
Bemerkung U-Stix
Item
Bemerkung Urinuntersuchung
string
Urinalysis dipstick test status (Code-1)
C1545794 (UMLS CUI-1)
MTHU017933 (LOINC-1)
Comment (Code-2)
C0947611 (UMLS CUI-2)
MTHU013736 (LOINC-2)
Item Group
Anamnese
Karnofsky Index
Item
Karnofsky Index
integer
Karnofsky Performance Status (Code-1)
C0206065 (UMLS CUI-1)
273546003 (SNOMED CT-1)
10054755 (MedDRA-1)
ECOG
Item
ECOG Leistungszustand
integer
C1632812 (UMLS CUI-1)
Patientin hat aktuell Beschwerden
Item
Beschwerden
boolean
Chief complaint (finding) (Code-1)
C0277786 (UMLS CUI-1)
409586006 (SNOMED CT-1)
MTHU001077 (LOINC-1)
Beschwerden
Item
Beschwerden
string
Chief complaint (finding) (Code-1)
C0277786 (UMLS CUI-1)
409586006 (SNOMED CT-1)
MTHU001077 (LOINC-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Patientin hatte im letzten Zyklus Beschwerden
Item
Menstuationsbeschwerden
boolean
Menstruation Disturbances (Code-1)
C0025345 (UMLS CUI-1)
289896006 (SNOMED CT-1)
10027327 (MedDRA-1)
Art der Beschwerden
Item
Symptome
string
Symptoms (Code-1)
C1457887 (UMLS CUI-1)
MTHU021540 (LOINC-1)
780-789,99 (ICD-9-CM-1)
Item
Grad der Beschwerden
integer
Symptom severity level (observable entity) (Code-1)
C1319166 (UMLS CUI-1)
162465004 (SNOMED CT-1)
MTHU038913 (LOINC-1)
Grad der Beschwerden
Code List
Grad der Beschwerden
CL Item
mild (1)
Symptom mild (finding) (Code-1)
C0436343 (UMLS CUI-1)
162468002 (SNOMED CT-1)
CL Item
moderat (2)
Symptom moderate (finding) (Code-1)
C0436344 (UMLS CUI-1)
162469005 (SNOMED CT-1)
CL Item
schwer (3)
Symptom severe (finding) (Code-1)
C0436345 (UMLS CUI-1)
162470006 (SNOMED CT-1)
CL Item
sehr schwer (4)
Symptom very severe (finding) (Code-1)
C0436346 (UMLS CUI-1)
162471005 (SNOMED CT-1)
Item Group
Therapie
Applikation komplikationslos via Port
Item
intravenös via Port
boolean
Intravenous Route of Drug Administration (Code-1)
C1522726 (UMLS CUI-1)
47625008 (SNOMED CT-1)
_IntravenousRoute (HL7 V3-1)
Portacath (Code-2)
C0935727 (UMLS CUI-2)
Applikation komplikationslos via PVK
Item
intravenös via PVK
boolean
Intravenous Route of Drug Administration (Code-1)
C1522726 (UMLS CUI-1)
47625008 (SNOMED CT-1)
_IntravenousRoute (HL7 V3-1)
Venous cannula (physical object) (Code-2)
C0179583 (UMLS CUI-2)
258621005 (SNOMED CT-2)
Chemotherapie appliziert
Item
Chemotherapie
boolean
Chemotherapy Regimen (Code-1)
C0392920 (UMLS CUI-1)
69960004 (SNOMED CT-1)
10061758 (MedDRA-1)
Chemotherapie
Item
Chemotherapie
string
Chemotherapy Regimen (Code-1)
C0392920 (UMLS CUI-1)
69960004 (SNOMED CT-1)
10061758 (MedDRA-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Bisphophonate appliziert
Item
Bisphosphonate
boolean
Diphosphonates (Code-1)
C0012544 (UMLS CUI-1)
372907000 (SNOMED CT-1)
Bisphophonate
Item
Bisphosphonate
string
Diphosphonates (Code-1)
C0012544 (UMLS CUI-1)
372907000 (SNOMED CT-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Endokrine Therapie eingenommen
Item
Hormon- / endokrine Therapie
boolean
C0279025 (UMLS CUI-1)
169413002 (SNOMED CT-1)
10065646 (MedDRA-1)
Endokrine Therapie
Item
Hormon- / endokrine Therapie
string
C0279025 (UMLS CUI-1)
169413002 (SNOMED CT-1)
10065646 (MedDRA-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Aktuelle Medikation
Item
Medikamente
string
Pharmaceutical Preparations (Code-1)
C0013227 (UMLS CUI-1)
410942007 (SNOMED CT-1)
Item Group
Rezepte
Item
Antiemetika
integer
changed_datatype (Code-Info)
Antiemetics (Code-1)
C0003297 (UMLS CUI-1)
372764000 (SNOMED CT-1)
Antiemese
Code List
Antiemetika
CL Item
Aprepitant  (Aprepitant (mitgegeben))
changed_datatype (Code-Info)
aprepitant (Code-1)
C1176306 (UMLS CUI-1)
409205009 (SNOMED CT-1)
CL Item
Ondansetron (Ondansetron)
changed_datatype (Code-Info)
Ondansetron (Code-1)
C0061851 (UMLS CUI-1)
372487007 (SNOMED CT-1)
CL Item
Dexamethason (Dexamethason)
changed_datatype (Code-Info)
Dexamethasone (Code-1)
C0011777 (UMLS CUI-1)
372584003 (SNOMED CT-1)
MTHU004621 (LOINC-1)
Item
Mukositis management
integer
changed_datatype (Code-Info)
Mucositis management (Code-1)
C0279839 (UMLS CUI-1)
Mucositisprophylaxe
Code List
Mukositis management
CL Item
therapeutische Gurgellösung (Mucositis-Gurgellösung (mitgegeben))
changed_datatype (Code-Info)
Therapeutic gargle (Code-1)
C2242590 (UMLS CUI-1)
10067984 (MedDRA-1)
CL Item
Ampho-Moronal-Suspension (Ampho-Moronal-Susp)
changed_datatype (Code-Info)
Amphotericin B Oral Suspension (Code-1)
C1244604 (UMLS CUI-1)
Item
andere Medikamente
integer
changed_datatype (Code-Info)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Pharmaceutical Preparations (Code-2)
C0013227 (UMLS CUI-2)
410942007 (SNOMED CT-2)
Sonstige
Code List
andere Medikamente
CL Item
Neulasta (primäre GCSF-Prophylaxe (Neulasta))
changed_datatype (Code-Info)
Neulasta (Code-1)
C1171279 (UMLS CUI-1)
CL Item
Antibiotikaprophylaxe (Antibiotikaprophylaxe)
changed_datatype (Code-Info)
antibiotics; administration, prophylactic (Code-1)
C1388076 (UMLS CUI-1)
CL Item
sonstige (Sonstige)
changed_datatype (Code-Info)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Item Group
nächster Chemotherapiezyklus
Datum und Uhrzeit Zyklus
Item
Datum nächster Chemotherapie Zyklus
date
Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Chemotherapy cycle (procedure) (Code-2)
C1302181 (UMLS CUI-2)
399042005 (SNOMED CT-2)
Next (Code-3)
CL414352 (UMLS CUI-3)
Bildgebung
Item
Bildgebung
string
Imaging, Medical (Code-1)
C0025086 (UMLS CUI-1)
Free Text Format (Code-2)
C2348713 (UMLS CUI-2)
Sonstiges
Item
sonstiges
string
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Unterschrift
Item
Unterschrift
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
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