ID
43367
Beschrijving
documentation standard - breast cancer - gynecology, with friendly permission (Dr. Tio) - kooperatives Brustzentrum Münster, Bereich Senologie an der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe - Leitung: Dr. med. Joke Tio
Trefwoorden
Versies (2)
- 15-05-13 15-05-13 -
- 20-09-21 20-09-21 -
Geüploaded op
20 september 2021
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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HIS talk after biopsy breast cancer
HIS
- StudyEvent: HIS
Beschrijving
Patienteninformation
Beschrijving
am
Datatype
date
Alias
- Code-1
- Visit Date
- UMLS CUI-1
- C1320303
- SNOMED CT-1
- 406543005
Beschrijving
durch Dr.
Datatype
string
Alias
- Code-1
- Responsible Person
- UMLS CUI-1
- C1273518
- SNOMED CT-1
- 394851003
Beschrijving
Histologie
Datatype
string
Alias
- Code-1
- Histopathology
- UMLS CUI-1
- C0677043
- SNOMED CT-1
- 394597005
- Code-2
- Biopsy
- UMLS CUI-2
- C0005558
- SNOMED CT-2
- 86273004
- MedDRA-2
- 10004720
- LOINC-2
- MTHU028106
Beschrijving
Operation
Beschrijving
DE
Datatype
boolean
Alias
- Code-Info
- changed_datatype
- Code-1
- Excisional Biopsy
- UMLS CUI-1
- C0184921
- SNOMED CT-1
- 8889005
- Code-2
- Plan
- UMLS CUI-2
- C1301732
- SNOMED CT-2
- 397943006
Beschrijving
BET
Datatype
boolean
Alias
- Code-Info
- changed_datatype
- Code-1
- Breast Conservation Treatment
- UMLS CUI-1
- C0917927
- Code-2
- Plan
- UMLS CUI-2
- C1301732
- SNOMED CT-2
- 397943006
Beschrijving
onkopl. BET
Datatype
boolean
Alias
- Code-Info
- changed_datatype
- Code-1
- Plastic Surgical Procedures
- UMLS CUI-1
- C0677616
- SNOMED CT-1
- 286553006
- MedDRA-1
- 10062082
- Code-2
- Breast Conservation Treatment
- UMLS CUI-2
- C0917927
- Code-3
- Plan
- UMLS CUI-3
- C1301732
- SNOMED CT-3
- 397943006
Beschrijving
ME
Datatype
boolean
Alias
- Code-Info
- changed_datatype
- Code-1
- Mastectomy
- UMLS CUI-1
- C0024881
- MedDRA-1
- 10026878
- ICD-9-CM-1
- 85.4
- Code-2
- Plan
- UMLS CUI-2
- C1301732
- SNOMED CT-2
- 397943006
Beschrijving
geplante Operation II
Datatype
integer
Alias
- UMLS CUI-1
- C0543467
- SNOMED CT-1
- 387713003
- MedDRA-1
- 10042609
- LOINC-1
- MTHU007597
- Code-2
- Plan
- UMLS CUI-2
- C1301732
- SNOMED CT-2
- 397943006
Beschrijving
SLN
Datatype
boolean
Alias
- Code-Info
- changed_datatype
- Code-1
- Sentinel Lymph Node Biopsy
- UMLS CUI-1
- C0796693
- SNOMED CT-1
- 396487001
- Code-2
- Plan
- UMLS CUI-2
- C1301732
- SNOMED CT-2
- 397943006
Beschrijving
aLNE
Datatype
boolean
Alias
- Code-Info
- changed_datatype
- Code-1
- Axillary Lymph Node Dissection
- UMLS CUI-1
- C0193867
- SNOMED CT-1
- 234254000
- MedDRA-1
- 10068477
- ICD-9-CM-1
- 40.23
- Code-2
- Plan
- UMLS CUI-2
- C1301732
- SNOMED CT-2
- 397943006
Beschrijving
Rekonstruktion gewünscht
Datatype
integer
Alias
- Code-1
- Reconstructive Surgical Procedures
- UMLS CUI-1
- C0524865
- SNOMED CT-1
- 122465003
- LOINC-1
- MTHU010401
Beschrijving
stationäre Aufnahme am
Datatype
date
Alias
- Code-1
- Date of admission
- UMLS CUI-1
- C1302393
- SNOMED CT-1
- 399423000
- LOINC-1
- MTHU029790
Beschrijving
verantwortlicher Operateur
Datatype
string
Alias
- Code-1
- primary surgeon
- UMLS CUI-1
- C0808118
- LOINC-1
- MTHU010488
- HL7 V3-1
- PRISURG
Beschrijving
Patienteninformation II
Beschrijving
Intention
Datatype
integer
Alias
- Code-Info
- normalized_coding
- Code-1
- Intention
- UMLS CUI-1
- C1283828
- SNOMED CT-1
- 367565008
- Code-2
- Chemotherapy Regimen
- UMLS CUI-2
- C0392920
- SNOMED CT-2
- 69960004
- MedDRA-2
- 10061758
- Code-3
- Plan
- UMLS CUI-3
- C1301732
- SNOMED CT-3
- 397943006
Beschrijving
Studie
Datatype
string
Alias
- UMLS CUI-1
- C0008976
- SNOMED CT-1
- 110465008
Beschrijving
Staging
Datatype
integer
Alias
- Code-1
- disease stage
- UMLS CUI-1
- C0699749
Beschrijving
Rö-Thorax
Datatype
boolean
Alias
- Code-1
- Radiographic imaging procedure
- UMLS CUI-1
- C1962945
- SNOMED CT-1
- 363680008
- MedDRA-1
- 10048064
- Code-2
- Thorax
- UMLS CUI-2
- C0817096
- SNOMED CT-2
- 51185008
Beschrijving
Rö-Thorax
Datatype
date
Alias
- Code-1
- Date in time
- UMLS CUI-1
- C0011008
- SNOMED CT-1
- 410671006
- LOINC-1
- MTHU021546
- Code-2
- Radiographic imaging procedure
- UMLS CUI-2
- C1962945
- SNOMED CT-2
- 363680008
- MedDRA-2
- 10048064
Beschrijving
Befund Rö-Thorax
Datatype
string
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- Radiographic imaging procedure
- UMLS CUI-2
- C1962945
- SNOMED CT-2
- 363680008
- MedDRA-2
- 10048064
- Code-3
- Free Text Format
- UMLS CUI-3
- C2348713
Beschrijving
Befund II Rö-Thorax
Datatype
integer
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- Radiographic imaging procedure
- UMLS CUI-2
- C1962945
- SNOMED CT-2
- 363680008
- MedDRA-2
- 10048064
Beschrijving
OB-Sono
Datatype
boolean
Alias
- Code-1
- Ultrasonography
- UMLS CUI-1
- C0041618
- SNOMED CT-1
- 16310003
- MedDRA-1
- 10045434
- LOINC-1
- MTHU000076
- CTCAE-1
- 12
- Code-2
- Abdomen
- UMLS CUI-2
- C0000726
- SNOMED CT-2
- 113345001
- LOINC-2
- MTHU001425
Beschrijving
OB-Sono
Datatype
date
Alias
- Code-1
- Ultrasonography
- UMLS CUI-1
- C0041618
- SNOMED CT-1
- 16310003
- MedDRA-1
- 10045434
- LOINC-1
- MTHU000076
Beschrijving
Befund OB-Sono
Datatype
string
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- Ultrasonography
- UMLS CUI-2
- C0041618
- SNOMED CT-2
- 16310003
- MedDRA-2
- 10045434
- LOINC-2
- MTHU000076
- Code-3
- Free Text Format
- UMLS CUI-3
- C2348713
Beschrijving
Befund II OB-Sono
Datatype
integer
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- Ultrasonography
- UMLS CUI-2
- C0041618
- SNOMED CT-2
- 16310003
- MedDRA-2
- 10045434
- LOINC-2
- MTHU000076
Beschrijving
Skelett-Szinitigr.
Datatype
boolean
Alias
- Code-1
- Radionuclide Imaging
- UMLS CUI-1
- C0034606
- SNOMED CT-1
- 399019003
- MedDRA-1
- 10061478
- ICD-9-CM-1
- 92
Beschrijving
Skelett-Szinitigr.
Datatype
date
Alias
- Code-1
- Radionuclide Imaging
- UMLS CUI-1
- C0034606
- SNOMED CT-1
- 399019003
- MedDRA-1
- 10061478
- ICD-9-CM-1
- 92
Beschrijving
Befund Skelett-Szinitigr.
Datatype
string
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- Radionuclide Imaging
- UMLS CUI-2
- C0034606
- SNOMED CT-2
- 399019003
- MedDRA-2
- 10061478
- ICD-9-CM-2
- 92
- Code-3
- Free Text Format
- UMLS CUI-3
- C2348713
Beschrijving
Befund II Skelett-Szinitigr.
Datatype
integer
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- Radionuclide Imaging
- UMLS CUI-2
- C0034606
- SNOMED CT-2
- 399019003
- MedDRA-2
- 10061478
- ICD-9-CM-2
- 92
Beschrijving
Computertomogr.
Datatype
boolean
Alias
- Code-1
- X-Ray Computed Tomography
- UMLS CUI-1
- C0040405
- SNOMED CT-1
- 77477000
- MedDRA-1
- 10010234
Beschrijving
Computertomogr.
Datatype
date
Alias
- Code-1
- X-Ray Computed Tomography
- UMLS CUI-1
- C0040405
- SNOMED CT-1
- 77477000
- MedDRA-1
- 10010234
Beschrijving
Befund Computertomogr.
Datatype
string
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- X-Ray Computed Tomography
- UMLS CUI-2
- C0040405
- SNOMED CT-2
- 77477000
- MedDRA-2
- 10010234
- Code-3
- Free Text Format
- UMLS CUI-3
- C2348713
Beschrijving
Befund II Computertomogr.
Datatype
integer
Alias
- Code-1
- Finding
- UMLS CUI-1
- C1285578
- SNOMED CT-1
- 363787002
- Code-2
- X-Ray Computed Tomography
- UMLS CUI-2
- C0040405
- SNOMED CT-2
- 77477000
- MedDRA-2
- 10010234
Beschrijving
Metastasen (M1)
Datatype
string
Alias
- Code-1
- Distant Metastasis
- UMLS CUI-1
- CL278860
Beschrijving
Patientin wünscht Zweitmeinung
Datatype
boolean
Alias
- Code-1
- Second Opinion
- UMLS CUI-1
- C0036524
- Code-2
- desire
- UMLS CUI-2
- C0871633
Beschrijving
Ort Zweitmeinung
Datatype
string
Alias
- Code-1
- Second Opinion
- UMLS CUI-1
- C0036524
- Code-2
- Place
- UMLS CUI-2
- C0442504
- SNOMED CT-2
- 257557008
Beschrijving
Unterschrift
Datatype
string
Alias
- Code-1
- Signature of responsible attending physician on file
- UMLS CUI-1
- C0807938
Similar models
HIS
- StudyEvent: HIS
C2706086 (UMLS CUI-1)
52463-7 (LOINC-1)
184100006 (SNOMED CT-1)
184096005 (SNOMED CT-1)
184095009 (SNOMED CT-1)
184099003 (SNOMED CT-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
Hour (Code-2)
C0439227 (UMLS CUI-2)
258702006 (SNOMED CT-2)
HR (HL7 V3-2)
C0809949 (UMLS CUI-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
PHYS (HL7 V3-2)
C1320303 (UMLS CUI-1)
406543005 (SNOMED CT-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Excisional Biopsy (Code-1)
C0184921 (UMLS CUI-1)
8889005 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Breast Conservation Treatment (Code-1)
C0917927 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Plastic Surgical Procedures (Code-1)
C0677616 (UMLS CUI-1)
286553006 (SNOMED CT-1)
10062082 (MedDRA-1)
Breast Conservation Treatment (Code-2)
C0917927 (UMLS CUI-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Mastectomy (Code-1)
C0024881 (UMLS CUI-1)
10026878 (MedDRA-1)
85.4 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
387713003 (SNOMED CT-1)
10042609 (MedDRA-1)
MTHU007597 (LOINC-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Sentinel Lymph Node Biopsy (Code-1)
C0796693 (UMLS CUI-1)
396487001 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
Axillary Lymph Node Dissection (Code-1)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
C0524865 (UMLS CUI-1)
122465003 (SNOMED CT-1)
MTHU010401 (LOINC-1)
C1514873 (UMLS CUI-1)
Negation (Code-2)
C1518422 (UMLS CUI-2)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
C0177682 (UMLS CUI-1)
85.95 (ICD-9-CM-1)
C0405407 (UMLS CUI-1)
172057008 (SNOMED CT-1)
Breast reconstruction with TRAM flap (procedure) (Code-1)
C1960508 (UMLS CUI-1)
70966003 (SNOMED CT-1)
10044333 (MedDRA-1)
DIEP Flap (Code-1)
C2985549 (UMLS CUI-1)
Intention (Code-1)
C1283828 (UMLS CUI-1)
367565008 (SNOMED CT-1)
Chemotherapy Regimen (Code-2)
C0392920 (UMLS CUI-2)
69960004 (SNOMED CT-2)
10061758 (MedDRA-2)
Plan (Code-3)
C1301732 (UMLS CUI-3)
397943006 (SNOMED CT-3)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
110465008 (SNOMED CT-1)
C0445204 (UMLS CUI-1)
262068006 (SNOMED CT-1)
C0032790 (UMLS CUI-1)
262061000 (SNOMED CT-1)
C1962945 (UMLS CUI-1)
363680008 (SNOMED CT-1)
10048064 (MedDRA-1)
Thorax (Code-2)
C0817096 (UMLS CUI-2)
51185008 (SNOMED CT-2)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
C0041618 (UMLS CUI-1)
16310003 (SNOMED CT-1)
10045434 (MedDRA-1)
MTHU000076 (LOINC-1)
12 (CTCAE-1)
Abdomen (Code-2)
C0000726 (UMLS CUI-2)
113345001 (SNOMED CT-2)
MTHU001425 (LOINC-2)
C0041618 (UMLS CUI-1)
16310003 (SNOMED CT-1)
10045434 (MedDRA-1)
MTHU000076 (LOINC-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Ultrasonography (Code-2)
C0041618 (UMLS CUI-2)
16310003 (SNOMED CT-2)
10045434 (MedDRA-2)
MTHU000076 (LOINC-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Ultrasonography (Code-2)
C0041618 (UMLS CUI-2)
16310003 (SNOMED CT-2)
10045434 (MedDRA-2)
MTHU000076 (LOINC-2)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radionuclide Imaging (Code-2)
C0034606 (UMLS CUI-2)
399019003 (SNOMED CT-2)
10061478 (MedDRA-2)
92 (ICD-9-CM-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radionuclide Imaging (Code-2)
C0034606 (UMLS CUI-2)
399019003 (SNOMED CT-2)
10061478 (MedDRA-2)
92 (ICD-9-CM-2)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
X-Ray Computed Tomography (Code-2)
C0040405 (UMLS CUI-2)
77477000 (SNOMED CT-2)
10010234 (MedDRA-2)
Free Text Format (Code-3)
C2348713 (UMLS CUI-3)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
X-Ray Computed Tomography (Code-2)
C0040405 (UMLS CUI-2)
77477000 (SNOMED CT-2)
10010234 (MedDRA-2)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
CL278860 (UMLS CUI-1)
C0036524 (UMLS CUI-1)
desire (Code-2)
C0871633 (UMLS CUI-2)
C0036524 (UMLS CUI-1)
Place (Code-2)
C0442504 (UMLS CUI-2)
257557008 (SNOMED CT-2)
C0807938 (UMLS CUI-1)
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