Patient Master Data
Unique health insurance number of patient, as to private health insurance you may use the insurance and/or contract number. With health assistance there is still clarification needed.
integer
Unique identification of an insurance company or health insurance company. It may be unknown
integer
Current family name of the patient at the day of reporting
text
Any academic title of a patient, all abbreviated and separated by "space". Examples: I.E; B.S; MD;Prof.; etc
text
Any suffix to a patient name. Examples: Baron of ; Lady; Baronesse; of; van; etc
text
Given names of a patient. More than one given name may be separated by "space"
text
Family name of patient at birth
text
Any previous names of a patient, maybe separated by "space"
text
Differentiation of a person by sexual characteristics
integer
Day month and year of a patient´s birth according to gregorian calendar
date
Current adress of a patient at the day of diagnosis or reporting
text
Number of the house or apartement the patient lives at. Alphanumerical with any suffix (a,b,c...)
text
Current country of a patient´s residence at the day of diagnosis and reporting
text
Current postal code of a patient´s residence at the day of diagnosis and reporting
integer
Current city of a patient´s residence at the day of diagnosis and reporting
text
Master data of reporting institution
Random but unique identification key given by a cancer registry responsible for the institution
text
Reporting Institution name
text
Name and given name of reporting physician
text
Street, house number and suffix of reporting institution
text
Postal code of the (german) reporting institution. Solely postal codes of 5 digits for Germany from 01001 to 99996 with prefixed zero
integer
City where the (german) reporting institution is located
text
Date the report has been delivered dd.mm.yyyy
date
Bank name of health care provider´s bank account
text
Name of health care provider who owns the bank account
text
Bank identifier code of health care provider´s account
text
International bank account number of healthcare provider´s account
text
Diagnosis
Coding of a notifiable disease according to current ICD-GM Version
integer
Designation of ICD Version used for coding
integer
Definition of a notifiable disease free text
text
Definition of the topography of a disease according to the current ICD-O Version(Currently 2013-O3 Version)
integer
Designation of ICD-O version used for coding. Example: Edition O3; first Edition 2003
text
Date specified in day, month and year on which the reportable diagnosis was first clinically or microscopically diagnosed by a physician. DD.MM.YYYY. Date unknown: Insert 00 unknown day and month: Insert 00:00
date
Highest reached diagnostic accuracy at the date of diagnosis:see also ICD-O,page 60 One digit,numerical
integer
Organ-specific indication of the affected side
integer
Neoplastic diseases that have been diagnosed or treated at an earlier time in the patients medical history Free text or ICD-10 diagnosis and indication of year of diagnosis YYYY
text
Histology
Date specified in day, month and year on which the reportable diagnosis was microscopically diagnosed. DD.MM.YYYY. Date unknown: Insert 00 unknown day and month: Insert 00:00
date
An alphanumeric identifier assigned by a receiving lab to specimens that have been received. Unique allocation which preparation was studied, for reference purposes.
text
Indicates the histology of a neoplasm. Alphanumerical, according to ICD-O Morphology (Current version)
text
Designation of ICD-O version used for coding. Example: Edition O3, first edition 2003
text
Indicates original designation of a morphological diagnosis, alphanumerical
text
Indicates the grade of differentiation of a neoplasm. The histopathologic grading of neoplasms is conducted to obtain evidence relating to their aggressiveness and to indicate to prognosis and treatment. The grading should follow recommendations of the WHO classification for malignant tumors. During classification all relevant provisions of literature (TNM) have to be followed.
text
Indicates how many lymph nodes have been examined,including sentinel
integer
Indicates how many lymph nodes have been affected,including sentinel
integer
Indicates how many sentinel lymph nodes have been examined
integer
Indicates how many sentinel lymph nodes have been affected
integer
TNM Classification
Indicates the date when the TNM classification was performed. dd.mm.yyyy
date
Indicates the version used for TNM classification. Example: 6= 6th edition; 7= 7th edition...
integer
Indicates whether classification was performed during or after multimodal treatment
text
Indicates whether the classification relates to a recurrent disease
text
Indicates whether classification was performed during autopsy
text
Indicates whether clinical or pathological staging was performed
text
Indicates whether clinical or pathological staging was performed
text
Indicates whether clinical or pathological staging was performed
text
Spread of the primary tumor, tumor entity according to TNM and TNM Supplement. Entity specific also see to TNM general comments
text
Indicates presence of multiple primary neoplasms in the same area
text
Spread of the primary tumor, tumor entity according to TNM and TNM Supplement. Entity specific also see to TNM general comments
text
Spread of the primary tumor, tumor entity according to TNM and TNM Supplement. Can be entity specific, including additional comments like (i+/-) and mol+/-)
text
lymphatic invasion
text
venous invasion
text
Perineural invasion
text
serum tumor marker S1–S3 =at least one serum tumor marker increased
text
Other classifications
Name of hematological or other classification. Type of classification and characteristics.Not standardized at this point,but is part of existing and modules to be defined. Example: Ann-Arbor WHO-neoplasms of the brain AJCC
text
Classification according to the hematologic or other classifications
text
Hemato-oncological and other classifications date
date
Residual status
Local assessment of residual classification after resection refers to the usually primary tumor which was resected, but i. E. also liver metastases
text
Overall assessment of residual classification of the disease including any distant metastases
text
Distant metastases
Localization of distant metastase(s)
text
Indicates when distant metastases have been diagnosed:dd.mm.yyyy
date
ECOG Performance Status
integer
Surgery
Indicates the objective of surgery
text
dd.mm.yyyy
date
Indicates what kind of procedure has been performed.Example: OPS (5-##.##)
text
Indicates after which version (year) of the OPS the procedure was classified: OPS and book edition Version 2013 Version 2014 ...
text
Complications
Indicates whether or not complications have occurred and if yes, what kind of complication If yes, then list the complications encountered by complication key
text
Radiotherapy
Indicates what the radiotherapy is aiming at. Unique classification of the intention of radiotherapy.
text
Indicates what relation the radiotherapy has to any surgical procedure
text
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the target of radiation
integer
Indicates the side of approach of targeted radiotherapy
text
Indicates when radiotherapy was started. dd.mm.yyyy
date
Indicates when radiotherapy was stopped. dd.mm.yyyy
date
Indicates the technique used for application of radiotherapy
text
Indicates the technique used for application of radiotherapy
text
Indicates the technique used for application of radiotherapy
text
Indicates the technique used for application of radiotherapy
text
Indicates the total dose the target was radiated with. Numerical with unit Gy or GBq
integer
Indicates the single dose the target was radiated with. The single dose refers to the prescribed iso dose. Numerical with unit Gy or GBq
integer
Indicates the reason for stopping radiotherapy
text
Radiotherapy Side effects
Indicates severity of side effects, during irradiation (so-called acute side effects until the 90th day after the start of irradiation) Type of side effect by CTC + Severity
text
Indicates what kind of side effects occurred during irradiation (so-called acute side effects until the 90th day after the start of irradiation)
text
Indicates the version of CTCAE used to account for side effects.
integer
Systemic therapy
Indicates what the systemic therapy is aiming at
text
Indicates what relation the systemic therapy has to any surgical procedure
text
Indicates the protocol used for systemic treatment.
text
Indicates when the systemic treatment was started. dd.mm.yyyy
date
Indicates the substance used for systemic treatment.
text
Indicates the reason why systemic therapy was stopped
text
Indicates the date systemic therapy was stopped. dd.mm.yyyy
date
Systemic or expectant treatment
Indicates what kind of systemic or expectant therapy has been performed. Multiple entries possible
text
Systemic therapy side effects
Indicates severity of side effects, during systemic therapy
text
Indicates what kind of side effects occurred during systemic therapy
text
Indicates the version of CTCAE used to account for side effects.
integer
Follow-Up
The date on which the final examination was carried out leading to the estimation of tumor status. dd.mm.yyyy
date
Overall disease evaluation taking into account all manifestations.
text
Assessment of the situation in the area of primary malignancy
text
Assessment of regional lymph nodes
text
Assessment of situation in the area of distant metastases
text
Tumor conference
Death
Date the patient died. dd.mm.yyyy
date
Indicates if the death was related to the malignancy
text
Cause of death according to ICD
text
Any further facts that are represented imprecisely in the coding of this document or go beyond, can be clarified here.
text
Indicates who performed the surgery. Depending on collaboration agreement and state law admissibility
text