ID

43549

Description

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Anamnese Brustsprechstunde MS.

Keywords

  1. 9/16/16 9/16/16 -
  2. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0

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Anamnesis Breast Consultation University Hospital Muenster (UKM)

Anamnesis Breast Consultation University Hospital Muenster (UKM)

Anamnese Brustsprechstunde
Description

Anamnese Brustsprechstunde

Alias
UMLS CUI-1
C0006141
UMLS CUI-2
C0025084
anamnesis date
Description

anamnesis date

Data type

date

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0011008
anamnesis person
Description

anamnesis person

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0010995
UMLS CUI [1,3]
C0027361
physician referral letter
Description

physician referral letter

Data type

text

Alias
UMLS CUI [1,1]
C0034927
UMLS CUI [1,2]
C0031831
reason for referral
Description

reason for referral

Data type

text

Alias
UMLS CUI [1,1]
C0034927
UMLS CUI [1,2]
C0392360
reason for consulation
Description

reason for consulation

Data type

text

Alias
UMLS CUI [1,1]
C0009818
UMLS CUI [1,2]
C0392360
body weight
Description

body weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
body height
Description

body height

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
menopause status
Description

menopause status

Data type

text

Alias
UMLS CUI [1]
C0025320
pregnancies
Description

pregnancies

Data type

integer

Alias
UMLS CUI [1]
C0032961
lactation
Description

lactation

Data type

integer

Alias
UMLS CUI [1,1]
C0006147
UMLS CUI [1,2]
C0439231
allergies
Description

allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
drink and tobacco
Description

drink and tobacco

Data type

text

Alias
UMLS CUI [1]
C0543414
UMLS CUI [2]
C0001948
cigarettes per day
Description

cigarettes per day

Data type

integer

Alias
UMLS CUI [1]
C3694146
thrombosis
Description

thrombosis

Data type

boolean

Alias
UMLS CUI [1]
C0040053
Current Medication
Description

Current Medication

medication
Description

medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Pre-existing Conditions
Description

Pre-existing Conditions

condition or surgery
Description

condition or surgery

Data type

text

Alias
UMLS CUI [1]
C0521987
UMLS CUI [2]
C0009488
condition date
Description

condition date

Data type

date

Alias
UMLS CUI [1,1]
C0521987
UMLS CUI [1,2]
C0011008
therapy
Description

therapy

Data type

text

Alias
UMLS CUI [1]
C0087111
External diagnoses
Description

External diagnoses

Alias
UMLS CUI-1
C0243095
UMLS CUI-2
C0205101
mammography
Description

mammography

Data type

boolean

Alias
UMLS CUI [1]
C0024671
mammography date
Description

mammography date

Data type

date

Alias
UMLS CUI [1,1]
C0024671
UMLS CUI [1,2]
C0011008
BIRADS right
Description

BIRADS right

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0205090
BIRADS left
Description

BIRADS left

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0205091
sonography
Description

sonography

Data type

boolean

Alias
UMLS CUI [1]
C0080264
sonography date
Description

sonography date

Data type

date

Alias
UMLS CUI [1,1]
C0080264
UMLS CUI [1,2]
C0011008
BIRADSanalog right
Description

BIRADSanalog right

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0205090
BIRADSanalog left
Description

BIRADSanalog left

Data type

text

Alias
UMLS CUI [1,1]
C1511314
UMLS CUI [1,2]
C0205091
MR-MG
Description

MR-MG

Data type

boolean

Alias
UMLS CUI [1]
C0344104
MR-MG date
Description

MR-MG date

Data type

date

Alias
UMLS CUI [1,1]
C0344104
UMLS CUI [1,2]
C0011008
MR-BIRADS right
Description

MR-BIRADS right

Data type

text

Alias
UMLS CUI [1,1]
C0917874
UMLS CUI [1,2]
C1511314
UMLS CUI [1,3]
C0205090
MR-BIRADS left
Description

MR-BIRADS left

Data type

text

Alias
UMLS CUI [1,1]
C0917874
UMLS CUI [1,2]
C1511314
UMLS CUI [1,3]
C0205091
histology
Description

histology

Data type

boolean

Alias
UMLS CUI [1]
C0019638
other external findings
Description

other external findings

Data type

boolean

Clinical finding
Description

Clinical finding

Alias
UMLS CUI-1
C0037088
cup size
Description

cup size

Data type

text

Alias
UMLS CUI [1]
C0425782
ptosis mammae
Description

ptosis mammae

Data type

text

Alias
UMLS CUI [1,1]
C0033377
UMLS CUI [1,2]
C0006141
breast symmetry
Description

breast symmetry

Data type

text

Alias
UMLS CUI [1]
C0425778
secretion
Description

secretion

Data type

text

Alias
UMLS CUI [1]
C1511310
Skin
Description

Skin

Alias
UMLS CUI-1
C1123023
skin findings
Description

skin findings

Data type

text

Alias
UMLS CUI [1]
C0455205
intradermal nodes
Description

intradermal nodes

Data type

boolean

Alias
UMLS CUI [1,1]
C0024103
UMLS CUI [1,2]
C0150647
inflammatory
Description

inflammatory

Data type

boolean

Alias
UMLS CUI [1]
C0333348
Breast
Description

Breast

Alias
UMLS CUI-1
C0006141
breast consistency
Description

breast consistency

Data type

text

Alias
UMLS CUI [1]
C1286084
palpation finding right
Description

palpation finding right

Data type

text

Alias
UMLS CUI [1,1]
C2032936
UMLS CUI [1,2]
C0750493
palpation finding right number
Description

palpation finding right number

Data type

integer

Alias
UMLS CUI [1,1]
C2032936
UMLS CUI [1,2]
C0750493
UMLS CUI [1,3]
C0449788
palpation finding left
Description

palpation finding left

Data type

text

Alias
UMLS CUI [1,1]
C2032933
UMLS CUI [1,2]
C0750493
palpation finding left number
Description

palpation finding left number

Data type

integer

Alias
UMLS CUI [1,1]
C2032933
UMLS CUI [1,2]
C0750493
UMLS CUI [1,3]
C0449788
lymphnodes right
Description

lymphnodes right

Data type

text

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C0222600
lymphnodes left
Description

lymphnodes left

Data type

text

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C0222601
comment
Description

comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Right Breast
Description

Right Breast

Alias
UMLS CUI-1
C0222600
clock
Description

clock

Data type

text

Alias
UMLS CUI [1,1]
C0442310
UMLS CUI [1,2]
C0205210
size
Description

size

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1,1]
C1290912
UMLS CUI [1,2]
C0456389
cm
suspicious finding
Description

suspicious finding

Data type

boolean

Alias
UMLS CUI [1,1]
C1290912
UMLS CUI [1,2]
C0750493
Left breast
Description

Left breast

Alias
UMLS CUI-1
C0222601
clock
Description

clock

Data type

text

Alias
UMLS CUI [1,1]
C0442310
UMLS CUI [1,2]
C0205210
size
Description

size

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1,1]
C1290912
UMLS CUI [1,2]
C0456389
cm
suspicious finding
Description

suspicious finding

Data type

boolean

Alias
UMLS CUI [1,1]
C1290912
UMLS CUI [1,2]
C0750493
Sonography of Breast Right
Description

Sonography of Breast Right

Alias
UMLS CUI-1
C0080264
UMLS CUI-2
C0205090
number
Description

number

Data type

integer

Alias
UMLS CUI [1]
C0237753
clock position
Description

clock position

Data type

text

Alias
UMLS CUI [1,1]
C0442310
UMLS CUI [1,2]
C0205210
metric
Description

metric

Data type

text

Alias
UMLS CUI [1,1]
C0449453
UMLS CUI [1,2]
C0080264
dignity BIRADS
Description

dignity BIRADS

Data type

text

Alias
UMLS CUI [1]
C1511314
lymphnodes right
Description

lymphnodes right

Data type

text

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C0222600
Sonography of Breast Left
Description

Sonography of Breast Left

Alias
UMLS CUI-1
C0080264
UMLS CUI-2
C0205091
number
Description

number

Data type

integer

Alias
UMLS CUI [1]
C0237753
clock position
Description

clock position

Data type

text

Alias
UMLS CUI [1,1]
C0442310
UMLS CUI [1,2]
C0205210
metric
Description

metric

Data type

text

Alias
UMLS CUI [1,1]
C0449453
UMLS CUI [1,2]
C0080264
dignity BIRADS
Description

dignity BIRADS

Data type

text

Alias
UMLS CUI [1]
C1511314
lymphnodes left
Description

lymphnodes left

Data type

text

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C0222601
Mammosonography
Description

Mammosonography

Alias
UMLS CUI-1
C0080264
biospy performed
Description

biospy performed

Data type

text

Alias
UMLS CUI [1]
C0005558
punch biopsy
Description

punch biopsy

Data type

boolean

Alias
UMLS CUI [1,1]
C0184924
UMLS CUI [1,2]
C0041618
puncture of cyst
Description

puncture of cyst

Data type

boolean

Alias
UMLS CUI [1]
C2733030
lesion
Description

lesion

Data type

text

Alias
UMLS CUI [1]
C0221198
number of punches
Description

number of punches

Data type

integer

Alias
UMLS CUI [1,1]
C0182557
UMLS CUI [1,2]
C0449788
change
Description

change

Data type

text

Alias
UMLS CUI [1]
C1515926
documented by photo
Description

documented by photo

Data type

boolean

Alias
UMLS CUI [1]
C0946283
date
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
signature
Description

signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Procedure
Description

Procedure

additional imaging
Description

additional imaging

Data type

boolean

Alias
UMLS CUI [1,1]
C1524062
UMLS CUI [1,2]
C0025086
mammography
Description

mammography

Data type

boolean

Alias
UMLS CUI [1]
C0024671
mammography date
Description

mammography date

Data type

date

Alias
UMLS CUI [1,1]
C0024671
UMLS CUI [1,2]
C0011008
sonography
Description

sonography

Data type

boolean

Alias
UMLS CUI [1]
C0041618
sonography date
Description

sonography date

Data type

date

Alias
UMLS CUI [1,1]
C0041618
UMLS CUI [1,2]
C0011008
other imaging
Description

other imaging

Data type

boolean

Alias
UMLS CUI [1]
C1533147
other imaging date
Description

other imaging date

Data type

date

Alias
UMLS CUI [1,1]
C1533147
UMLS CUI [1,2]
C0011008
registration
Description

registration

Data type

boolean

Alias
UMLS CUI [1]
C1514821
registration MDT
Description

registration MDT

Data type

boolean

registration MDT date
Description

registration MDT date

Data type

date

registration tumor conference
Description

registration tumor conference

Data type

boolean

registration tumor conference date
Description

registration tumor conference date

Data type

date

regular prevention
Description

regular prevention

Data type

boolean

Alias
UMLS CUI [1]
C2700409
follow-up visit
Description

follow-up visit

Data type

boolean

Alias
UMLS CUI [1]
C0589121
follow-up visits date
Description

follow-up visits date

Data type

date

Alias
UMLS CUI [1,1]
C0589121
UMLS CUI [1,2]
C0011008
date
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
signature
Description

signature

Data type

text

Alias
UMLS CUI [1]
C1519316

Similar models

Anamnesis Breast Consultation University Hospital Muenster (UKM)

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Anamnese Brustsprechstunde
C0006141 (UMLS CUI-1)
C0025084 (UMLS CUI-2)
anamnesis date
Item
date
C0025084 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
anamnesis person
Item
text
C0025084 (UMLS CUI [1,1])
C0010995 (UMLS CUI [1,2])
C0027361 (UMLS CUI [1,3])
physician referral letter
Item
text
C0034927 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
reason for referral
Item
text
C0034927 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Item
text
C0009818 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Code List
reason for consulation
CL Item
 (Vorsorge)
CL Item
 (Nachsorge)
CL Item
 (Selbstuntersuchung)
CL Item
 (Zufallsbefund)
CL Item
 (Symptomatik)
CL Item
 (Screening)
body weight
Item
float
C0005910 (UMLS CUI [1])
body height
Item
float
C0005890 (UMLS CUI [1])
Item
text
C0025320 (UMLS CUI [1])
Code List
menopause status
CL Item
 (prämenopause)
CL Item
 (postmenopause)
CL Item
 (perimenopausal)
CL Item
 (unbekannt)
pregnancies
Item
integer
C0032961 (UMLS CUI [1])
lactation
Item
integer
C0006147 (UMLS CUI [1,1])
C0439231 (UMLS CUI [1,2])
allergies
Item
text
C0020517 (UMLS CUI [1])
Item
text
C0543414 (UMLS CUI [1])
C0001948 (UMLS CUI [2])
Code List
drink and tobacco
CL Item
 (Nikotin)
CL Item
 (Alkohol)
cigarettes per day
Item
integer
C3694146 (UMLS CUI [1])
thrombosis
Item
boolean
C0040053 (UMLS CUI [1])
medication
Item
text
C0013227 (UMLS CUI [1])
condition or surgery
Item
text
C0521987 (UMLS CUI [1])
C0009488 (UMLS CUI [2])
condition date
Item
date
C0521987 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
therapy
Item
text
C0087111 (UMLS CUI [1])
Item Group
C0243095 (UMLS CUI-1)
C0205101 (UMLS CUI-2)
mammography
Item
boolean
C0024671 (UMLS CUI [1])
mammography date
Item
date
C0024671 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
text
C1511314 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Code List
BIRADS right
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
Item
text
C1511314 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Code List
BIRADS left
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
sonography
Item
boolean
C0080264 (UMLS CUI [1])
sonography date
Item
date
C0080264 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
text
C1511314 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Code List
BIRADSanalog right
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
Item
text
C1511314 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Code List
BIRADSanalog left
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
MR-MG
Item
boolean
C0344104 (UMLS CUI [1])
MR-MG date
Item
date
C0344104 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
text
C0917874 (UMLS CUI [1,1])
C1511314 (UMLS CUI [1,2])
C0205090 (UMLS CUI [1,3])
Code List
MR-BIRADS right
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
Item
text
C0917874 (UMLS CUI [1,1])
C1511314 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,3])
Code List
MR-BIRADS left
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
histology
Item
boolean
C0019638 (UMLS CUI [1])
other external findings
Item
boolean
Item Group
C0037088 (UMLS CUI-1)
Item
text
C0425782 (UMLS CUI [1])
Code List
cup size
CL Item
 (A)
CL Item
 (B)
CL Item
 (C)
CL Item
 (D)
CL Item
 (>D)
Item
text
C0033377 (UMLS CUI [1,1])
C0006141 (UMLS CUI [1,2])
Code List
ptosis mammae
CL Item
 (keine)
CL Item
 (mittel)
CL Item
 (ausgeprägt)
Item
text
C0425778 (UMLS CUI [1])
Code List
breast symmetry
CL Item
 (ja)
CL Item
 (li > re)
CL Item
 (nein)
CL Item
 (li < re)
Item
text
C1511310 (UMLS CUI [1])
Code List
secretion
CL Item
 (blutig)
CL Item
 (ja)
CL Item
 (milchig)
CL Item
 (nein)
CL Item
 (serös)
Item Group
C1123023 (UMLS CUI-1)
Item
text
C0455205 (UMLS CUI [1])
Code List
skin findings
CL Item
 (unauffällig)
CL Item
 (Einziehung)
CL Item
 (Plateau)
CL Item
 (Ödem)
CL Item
 (Ulzeration)
intradermal nodes
Item
boolean
C0024103 (UMLS CUI [1,1])
C0150647 (UMLS CUI [1,2])
inflammatory
Item
boolean
C0333348 (UMLS CUI [1])
Item Group
C0006141 (UMLS CUI-1)
Item
text
C1286084 (UMLS CUI [1])
Code List
breast consistency
CL Item
 (weich, gut beurteilbar)
CL Item
 (knotig, schwer beurteilbar)
Item
text
C2032936 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
Code List
palpation finding right
CL Item
 (nein (nonpalpabel))
CL Item
 (solitär)
CL Item
 (multiple)
palpation finding right number
Item
integer
C2032936 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
Item
text
C2032933 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
Code List
palpation finding left
CL Item
 (nein (nonpalpabel))
CL Item
 (solitär)
CL Item
 (multiple)
Item
integer
C2032933 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
Code List
palpation finding left number
lymphnodes right
Item
text
C0024204 (UMLS CUI [1,1])
C0222600 (UMLS CUI [1,2])
lymphnodes left
Item
text
C0024204 (UMLS CUI [1,1])
C0222601 (UMLS CUI [1,2])
comment
Item
text
C0947611 (UMLS CUI [1])
Item Group
C0222600 (UMLS CUI-1)
clock
Item
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
size
Item
integer
C1290912 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
suspicious finding
Item
boolean
C1290912 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
Item Group
C0222601 (UMLS CUI-1)
clock
Item
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
size
Item
integer
C1290912 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
suspicious finding
Item
boolean
C1290912 (UMLS CUI [1,1])
C0750493 (UMLS CUI [1,2])
Item Group
C0080264 (UMLS CUI-1)
C0205090 (UMLS CUI-2)
number
Item
integer
C0237753 (UMLS CUI [1])
clock position
Item
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
metric
Item
text
C0449453 (UMLS CUI [1,1])
C0080264 (UMLS CUI [1,2])
Item
text
C1511314 (UMLS CUI [1])
Code List
dignity BIRADS
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
lymphnodes right
Item
text
C0024204 (UMLS CUI [1,1])
C0222600 (UMLS CUI [1,2])
Item Group
C0080264 (UMLS CUI-1)
C0205091 (UMLS CUI-2)
number
Item
integer
C0237753 (UMLS CUI [1])
clock position
Item
text
C0442310 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
metric
Item
text
C0449453 (UMLS CUI [1,1])
C0080264 (UMLS CUI [1,2])
Item
text
C1511314 (UMLS CUI [1])
Code List
dignity BIRADS
CL Item
 (I)
CL Item
 (II)
CL Item
 (III)
CL Item
 (IV)
CL Item
 (V)
lymphnodes left
Item
text
C0024204 (UMLS CUI [1,1])
C0222601 (UMLS CUI [1,2])
Item Group
C0080264 (UMLS CUI-1)
biospy performed
Item
text
C0005558 (UMLS CUI [1])
punch biopsy
Item
boolean
C0184924 (UMLS CUI [1,1])
C0041618 (UMLS CUI [1,2])
puncture of cyst
Item
boolean
C2733030 (UMLS CUI [1])
lesion
Item
text
C0221198 (UMLS CUI [1])
number of punches
Item
integer
C0182557 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Item
text
C1515926 (UMLS CUI [1])
Code List
change
CL Item
 (nein )
CL Item
 (kleiner)
CL Item
 (weg)
documented by photo
Item
boolean
C0946283 (UMLS CUI [1])
date
Item
date
C0011008 (UMLS CUI [1])
signature
Item
text
C1519316 (UMLS CUI [1])
Item Group
additional imaging
Item
boolean
C1524062 (UMLS CUI [1,1])
C0025086 (UMLS CUI [1,2])
mammography
Item
boolean
C0024671 (UMLS CUI [1])
mammography date
Item
date
C0024671 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
sonography
Item
boolean
C0041618 (UMLS CUI [1])
sonography date
Item
date
C0041618 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
other imaging
Item
boolean
C1533147 (UMLS CUI [1])
other imaging date
Item
date
C1533147 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
registration
Item
boolean
C1514821 (UMLS CUI [1])
registration MDT
Item
boolean
registration MDT date
Item
date
registration tumor conference
Item
boolean
registration tumor conference date
Item
date
regular prevention
Item
boolean
C2700409 (UMLS CUI [1])
follow-up visit
Item
boolean
C0589121 (UMLS CUI [1])
follow-up visits date
Item
date
C0589121 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
date
Item
date
C0011008 (UMLS CUI [1])
signature
Item
text
C1519316 (UMLS CUI [1])

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