ID

43367

Description

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

Keywords

Versions (2)
  1. 15/05/2013 15/05/2013 -
  2. 20/09/2021 20/09/2021 -
Uploaded on

20 de setembro de 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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HIS talk after biopsy breast cancer

German English

HIS

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

Patientenaufkleber groß

Aufnahmedatum
Description

Aufnahmedatum

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Patientenidentifikationsnummer
Description

PatientenID

Data type

integer

Alias
Code-1
Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal
UMLS CUI-1
C2706086
LOINC-1
52463-7
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
Aufnahmezeit
Description

Aufnahmezeit

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Code-2
Hour
UMLS CUI-2
C0439227
SNOMED CT-2
258702006
HL7 V3-2
HR
Einweisender Arzt
Description

E-Arzt

Data type

string

Alias
Code-1
Admission
UMLS CUI-1
C0809949
Code-2
Physicians
UMLS CUI-2
C0031831
SNOMED CT-2
112247003
LOINC-2
MTHU010489
HL7 V3-2
PHYS
Patienteninformation
Description

Patienteninformation

Datum
Description

am

Data type

date

Alias
Code-1
Visit Date
UMLS CUI-1
C1320303
SNOMED CT-1
406543005
verantwortliche Person
Description

durch Dr.

Data type

string

Alias
Code-1
Responsible Person
UMLS CUI-1
C1273518
SNOMED CT-1
394851003
Histologie
Description

Histologie

Data type

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
Operation
Description

Operation

Excisionsbiopsie
Description

DE

Data type

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
Brusterhaltende Therapie
Description

BET

Data type

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
rekonstruktive brusterhaltende Therapie
Description

onkopl. BET

Data type

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
Mastektomie
Description

ME

Data type

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
Operation
Description

geplante Operation II

Data type

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
Sentinel Lymphknoten Biopsie
Description

SLN

Data type

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
Axilladissektion
Description

aLNE

Data type

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
Rekonstruktion
Description

Rekonstruktion gewünscht

Data type

integer

Alias
Code-1
Reconstructive Surgical Procedures
UMLS CUI-1
C0524865
SNOMED CT-1
122465003
LOINC-1
MTHU010401
Aufnahmedatum
Description

stationäre Aufnahme am

Data type

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
erster Operateur
Description

verantwortlicher Operateur

Data type

string

Alias
Code-1
primary surgeon
UMLS CUI-1
C0808118
LOINC-1
MTHU010488
HL7 V3-1
PRISURG
Patienteninformation II
Description

Patienteninformation II

Intent Chemotherapie
Description

Intention

Data type

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
klinische Studie
Description

Studie

Data type

string

Alias
UMLS CUI-1
C0008976
SNOMED CT-1
110465008
Staging
Description

Staging

Data type

integer

Alias
Code-1
disease stage
UMLS CUI-1
C0699749
Röntgen Thorax
Description

Rö-Thorax

Data type

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
Datum Röntgen Thorax
Description

Rö-Thorax

Data type

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
Befund Röntgen Thorax - Freitext
Description

Befund Rö-Thorax

Data type

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
Befund Röntgen Thorax
Description

Befund II Rö-Thorax

Data type

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
Sonographie Abdomen
Description

OB-Sono

Data type

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
Datum Sonographie Abdomen
Description

OB-Sono

Data type

date

Alias
Code-1
Ultrasonography
UMLS CUI-1
C0041618
SNOMED CT-1
16310003
MedDRA-1
10045434
LOINC-1
MTHU000076
Befund Sonographie Abdomen - Freitext
Description

Befund OB-Sono

Data type

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
Befund Sonographie Abdomen
Description

Befund II OB-Sono

Data type

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
Szinitgraphie
Description

Skelett-Szinitigr.

Data type

boolean

Alias
Code-1
Radionuclide Imaging
UMLS CUI-1
C0034606
SNOMED CT-1
399019003
MedDRA-1
10061478
ICD-9-CM-1
92
Datum Szintigraphie
Description

Skelett-Szinitigr.

Data type

date

Alias
Code-1
Radionuclide Imaging
UMLS CUI-1
C0034606
SNOMED CT-1
399019003
MedDRA-1
10061478
ICD-9-CM-1
92
Befund Szintigraphie - Freitext
Description

Befund Skelett-Szinitigr.

Data type

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
Befund Szintigraphie
Description

Befund II Skelett-Szinitigr.

Data type

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
Computertomographie
Description

Computertomogr.

Data type

boolean

Alias
Code-1
X-Ray Computed Tomography
UMLS CUI-1
C0040405
SNOMED CT-1
77477000
MedDRA-1
10010234
Datum Computertomographie
Description

Computertomogr.

Data type

date

Alias
Code-1
X-Ray Computed Tomography
UMLS CUI-1
C0040405
SNOMED CT-1
77477000
MedDRA-1
10010234
Befund Computertomographie - Freitext
Description

Befund Computertomogr.

Data type

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
Befund Computertomographie
Description

Befund II Computertomogr.

Data type

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
Fernmetastasen
Description

Metastasen (M1)

Data type

string

Alias
Code-1
Distant Metastasis
UMLS CUI-1
CL278860
Zweitmeinung erwünscht
Description

Patientin wünscht Zweitmeinung

Data type

boolean

Alias
Code-1
Second Opinion
UMLS CUI-1
C0036524
Code-2
desire
UMLS CUI-2
C0871633
Ort Zweitmeinung
Description

Ort Zweitmeinung

Data type

string

Alias
Code-1
Second Opinion
UMLS CUI-1
C0036524
Code-2
Place
UMLS CUI-2
C0442504
SNOMED CT-2
257557008
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
Aufnahmedatum
Item
Aufnahmedatum
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
PatientenID
Item
Patientenidentifikationsnummer
integer
Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal (Code-1)
C2706086 (UMLS CUI-1)
52463-7 (LOINC-1)
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)
Aufnahmezeit
Item
Aufnahmezeit
date
Date of admission (Code-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)
E-Arzt
Item
Einweisender Arzt
string
Admission (Code-1)
C0809949 (UMLS CUI-1)
Physicians (Code-2)
C0031831 (UMLS CUI-2)
112247003 (SNOMED CT-2)
MTHU010489 (LOINC-2)
PHYS (HL7 V3-2)
Item Group
Patienteninformation
am
Item
Datum
date
Visit Date (Code-1)
C1320303 (UMLS CUI-1)
406543005 (SNOMED CT-1)
durch Dr.
Item
verantwortliche Person
string
Responsible Person (Code-1)
C1273518 (UMLS CUI-1)
394851003 (SNOMED CT-1)
Histologie
Item
Histologie
string
Histopathology (Code-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)
Item Group
Operation
DE
Item
Excisionsbiopsie
boolean
changed_datatype (Code-Info)
Excisional Biopsy (Code-1)
C0184921 (UMLS CUI-1)
8889005 (SNOMED CT-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
BET
Item
Brusterhaltende Therapie
boolean
changed_datatype (Code-Info)
Breast Conservation Treatment (Code-1)
C0917927 (UMLS CUI-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
onkopl. BET
Item
rekonstruktive brusterhaltende Therapie
boolean
changed_datatype (Code-Info)
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)
ME
Item
Mastektomie
boolean
changed_datatype (Code-Info)
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)
geplante Operation II
Item
Operation
integer
C0543467 (UMLS CUI-1)
387713003 (SNOMED CT-1)
10042609 (MedDRA-1)
MTHU007597 (LOINC-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
SLN
Item
Sentinel Lymphknoten Biopsie
boolean
changed_datatype (Code-Info)
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)
aLNE
Item
Axilladissektion
boolean
changed_datatype (Code-Info)
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)
Item
Rekonstruktion
integer
Reconstructive Surgical Procedures (Code-1)
C0524865 (UMLS CUI-1)
122465003 (SNOMED CT-1)
MTHU010401 (LOINC-1)
Rekonstruktion gewünscht
Code List
Rekonstruktion
CL Item
nicht notwendig (nicht notwendig)
Requirement (Code-1)
C1514873 (UMLS CUI-1)
Negation (Code-2)
C1518422 (UMLS CUI-2)
CL Item
Nein (nein, aber Aufklärung erfolgt)
No (Code-1)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Ja (ja)
Yes (Code-1)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
Expander (Implantat/Expander)
Insertion of breast tissue expander (Code-1)
C0177682 (UMLS CUI-1)
85.95 (ICD-9-CM-1)
CL Item
Latissimus dorsi Muskel-Unterhaut-Lappen (Lat. Dorsi)
Reconstruction of breast using myocutaneous flap of latissimus dorsi muscle (procedure) (Code-1)
C0405407 (UMLS CUI-1)
172057008 (SNOMED CT-1)
CL Item
Transverser Rectus Abdominis Musculocutaneus-Lappen (TRAM)
extended_coding (Code-Info)
Breast reconstruction with TRAM flap (procedure) (Code-1)
C1960508 (UMLS CUI-1)
70966003 (SNOMED CT-1)
10044333 (MedDRA-1)
CL Item
Tiefer inferiorer epigastrischer Perforatorlappen (DIEP)
extended_coding (Code-Info)
DIEP Flap (Code-1)
C2985549 (UMLS CUI-1)
stationäre Aufnahme am
Item
Aufnahmedatum
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
verantwortlicher Operateur
Item
erster Operateur
string
primary surgeon (Code-1)
C0808118 (UMLS CUI-1)
MTHU010488 (LOINC-1)
PRISURG (HL7 V3-1)
Item Group
Patienteninformation II
Item
Intent Chemotherapie
integer
normalized_coding (Code-Info)
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)
Intention
Code List
Intent Chemotherapie
CL Item
Neoadjuvant (N = neoadjuvant)
normalized_coding (Code-Info)
Neo-adjuvant - intent (qualifier value) (Code-1)
C1298676 (UMLS CUI-1)
373847000 (SNOMED CT-1)
Studie
Item
klinische Studie
string
C0008976 (UMLS CUI-1)
110465008 (SNOMED CT-1)
Item
Staging
integer
disease stage (Code-1)
C0699749 (UMLS CUI-1)
Staging
Code List
Staging
CL Item
präoperativ (präoperativ)
Preoperative (Code-1)
C0445204 (UMLS CUI-1)
262068006 (SNOMED CT-1)
CL Item
postoperativ (postoperativ)
Postoperative (Code-1)
C0032790 (UMLS CUI-1)
262061000 (SNOMED CT-1)
Rö-Thorax
Item
Röntgen Thorax
boolean
Radiographic imaging procedure (Code-1)
C1962945 (UMLS CUI-1)
363680008 (SNOMED CT-1)
10048064 (MedDRA-1)
Thorax (Code-2)
C0817096 (UMLS CUI-2)
51185008 (SNOMED CT-2)
Rö-Thorax
Item
Datum Röntgen Thorax
date
Date in time (Code-1)
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)
Befund Rö-Thorax
Item
Befund Röntgen Thorax - Freitext
string
Finding (Code-1)
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)
Item
Befund Röntgen Thorax
integer
Finding (Code-1)
C1285578 (UMLS CUI-1)
363787002 (SNOMED CT-1)
Radiographic imaging procedure (Code-2)
C1962945 (UMLS CUI-2)
363680008 (SNOMED CT-2)
10048064 (MedDRA-2)
Befund II Rö-Thorax
Code List
Befund Röntgen Thorax
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
OB-Sono
Item
Sonographie Abdomen
boolean
Ultrasonography (Code-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)
OB-Sono
Item
Datum Sonographie Abdomen
date
Ultrasonography (Code-1)
C0041618 (UMLS CUI-1)
16310003 (SNOMED CT-1)
10045434 (MedDRA-1)
MTHU000076 (LOINC-1)
Befund OB-Sono
Item
Befund Sonographie Abdomen - Freitext
string
Finding (Code-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)
Item
Befund Sonographie Abdomen
integer
Finding (Code-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)
Befund II OB-Sono
Code List
Befund Sonographie Abdomen
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Skelett-Szinitigr.
Item
Szinitgraphie
boolean
Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)
Skelett-Szinitigr.
Item
Datum Szintigraphie
date
Radionuclide Imaging (Code-1)
C0034606 (UMLS CUI-1)
399019003 (SNOMED CT-1)
10061478 (MedDRA-1)
92 (ICD-9-CM-1)
Befund Skelett-Szinitigr.
Item
Befund Szintigraphie - Freitext
string
Finding (Code-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)
Item
Befund Szintigraphie
integer
Finding (Code-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)
Befund II Skelett-Szinitigr.
Code List
Befund Szintigraphie
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Computertomogr.
Item
Computertomographie
boolean
X-Ray Computed Tomography (Code-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)
Computertomogr.
Item
Datum Computertomographie
date
X-Ray Computed Tomography (Code-1)
C0040405 (UMLS CUI-1)
77477000 (SNOMED CT-1)
10010234 (MedDRA-1)
Befund Computertomogr.
Item
Befund Computertomographie - Freitext
string
Finding (Code-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)
Item
Befund Computertomographie
integer
Finding (Code-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)
Befund II Computertomogr.
Code List
Befund Computertomographie
CL Item
unauffällig (unauffällig)
Normal (Code-1)
C0205307 (UMLS CUI-1)
17621005 (SNOMED CT-1)
CL Item
auffällig (auffällig)
Abnormal (Code-1)
C0205161 (UMLS CUI-1)
263654008 (SNOMED CT-1)
Metastasen (M1)
Item
Fernmetastasen
string
Distant Metastasis (Code-1)
CL278860 (UMLS CUI-1)
Patientin wünscht Zweitmeinung
Item
Zweitmeinung erwünscht
boolean
Second Opinion (Code-1)
C0036524 (UMLS CUI-1)
desire (Code-2)
C0871633 (UMLS CUI-2)
Ort Zweitmeinung
Item
Ort Zweitmeinung
string
Second Opinion (Code-1)
C0036524 (UMLS CUI-1)
Place (Code-2)
C0442504 (UMLS CUI-2)
257557008 (SNOMED CT-2)
Unterschrift
Item
Unterschrift
string
Signature of responsible attending physician on file (Code-1)
C0807938 (UMLS CUI-1)
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