ID

44652

Descrição

quality management forms, with friendly permission, (http://www.sqg.de/downloads/2013/SR3/Dokumentationsboegen/18-1.pdf) AQUA - Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH

Link

http://www.sqg.de/downloads/2013/SR3/Dokumentationsboegen/18-1.pdf

Palavras-chave

  1. 07/08/2013 07/08/2013 -
  2. 27/09/2021 27/09/2021 -
Transferido a

27 de setembro de 2021

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy

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quality management AQUA breast surgery breast cancer

quality management

  1. StudyEvent: quality management
    1. quality management
Mammachirurgie
Descrição

Mammachirurgie

Basis
Descrição

Basis

Identifikationsnummer der Meldequelle
Descrição

Institutionskennzeichen

Tipo de dados

string

Alias
Code-1
Registration Authority
UMLS CUI-1
C2699022
nicht_sinnvoll_für_Untersuchung
Descrição

Betriebstätten-Nr

Tipo de dados

integer

Institution
Descrição

Fachabteilung

Tipo de dados

integer

Alias
UMLS CUI-1
C0021622
Identifikationsnummer der Patientin
Descrição

Identifikationsnummer der Patientin

Tipo de dados

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
Patienten-Geburtsdatum
Descrição

Geburtsdatum

Tipo de dados

date

Alias
UMLS CUI-1
C0421451
SNOMED CT-1
184099003
Patienten-Geschlecht
Descrição

Geschlecht

Tipo de dados

integer

Alias
UMLS CUI-1
C0150831
SNOMED CT-1
184100006
Aufnahmedatum
Descrição

Aufnahmedatum Krankenhaus

Tipo de dados

date

Alias
Code-1
Date of admission
UMLS CUI-1
C1302393
SNOMED CT-1
399423000
LOINC-1
MTHU029790
Aufnahmediagnose
Descrição

Aufnahmediagnose

Tipo de dados

string

Alias
Code-1
ADMITTING DIAGNOSIS
UMLS CUI-1
C0332133
SNOMED CT-1
52870002
ASA
Descrição

Einstufung nach ASA-Klassifikation

Tipo de dados

integer

Alias
Code-1
Finding of American Society of Anesthesiologists physical status classification (finding)
UMLS CUI-1
C1531480
SNOMED CT-1
413347006
Brust
Descrição

Brust

Körperseite
Descrição

betroffene Seite

Tipo de dados

integer

Alias
UMLS CUI-1
C0441987
SNOMED CT-1
182353008
LOINC-1
MTHU014973
Code-2
Tumor site
UMLS CUI-2
C0475445
SNOMED CT-2
263591006
LOINC-2
MTHU015562
Stadium
Descrição

Erkrankung an der Brust

Tipo de dados

integer

Alias
Code-1
Stage
UMLS CUI-1
C1300072
SNOMED CT-1
371508000
Erste Operation - Primärtumor
Descrição

Aufnahme zum ersten offenen Eingriff an dieser Brust wegen Primärerkrankung

Tipo de dados

boolean

Alias
Code-1
First
UMLS CUI-1
C0205435
SNOMED CT-1
255216001
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Code-3
Primary Malignant Neoplasm
UMLS CUI-3
C1306459
SNOMED CT-3
372087000
Tastbarer Mamma-Befund
Descrição

tastbarer Mammabefund

Tipo de dados

boolean

Alias
Code-1
Palpatory diagnosis (qualifier value)
UMLS CUI-1
C1562881
SNOMED CT-1
416400009
Code-2
Breast
UMLS CUI-2
C0006141
SNOMED CT-2
76752008
LOINC-2
MTHU011382
Grund des Arztbesuches
Descrição

Anlass der Diagnosestellung bekannt

Tipo de dados

integer

Alias
Code-1
Reason for patient visit
UMLS CUI-1
C1704447
SNOMED CT-1
103324002
LOINC-1
MTHU013910
prätherapeutischer histologischer Befund
Descrição

prätherapeutische histologische Diagnostik

Tipo de dados

boolean

Alias
Code-1
Histological finding
UMLS CUI-1
C0449575
SNOMED CT-1
263540008
Code-2
Prior
UMLS CUI-2
C0332152
SNOMED CT-2
288556008
Code-3
Therapeutic procedure
UMLS CUI-3
C0087111
SNOMED CT-3
277132007
MedDRA-3
10053757
LOINC-3
MTHU008880
Histologie
Descrição

Histologie

Tipo de dados

integer

Alias
Code-1
Histologic Type
UMLS CUI-1
C0449574
SNOMED CT-1
263541007
LOINC-1
MTHU020048
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Histologie-Code ICD-0-3
Descrição

maligne Neoplasie

Tipo de dados

string

Alias
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Biopsy
UMLS CUI-2
C0005558
SNOMED CT-2
86273004
MedDRA-2
10004720
LOINC-2
MTHU028106
Datum Pathologie Befund
Descrição

Datum (Ausgang Pathologie) des prätherapeutischen histologischen Befundes

Tipo de dados

date

Alias
Code-1
Date of pathology report (observable entity)
UMLS CUI-1
C1302659
SNOMED CT-1
399737008
Tumorkonferenz
Descrição

interdisziplinäre Therapieplanung

Tipo de dados

integer

Alias
Code-Info
changed_datatype
Code-1
Cancer conference
UMLS CUI-1
C0805438
LOINC-1
MTHU010336
Code-2
Type - attribute
UMLS CUI-2
C0332307
SNOMED CT-2
410656007
LOINC-2
MTHU013727
Datum der Konferenz
Descrição

Datum der Therapieplanung

Tipo de dados

date

Alias
Code-1
Cancer conference:Time Stamp -- Date and Time:Point in time:Cancer.To be specified in another part of the message:Quantitative
UMLS CUI-1
C0804663
LOINC-1
21875-0
präoperative Therapie
Descrição

präoperative tumorspezifische Therapie

Tipo de dados

integer

Alias
Code-Info
changed_datatype
Code-1
Therapeutic procedure
UMLS CUI-1
C0087111
SNOMED CT-1
277132007
MedDRA-1
10053757
LOINC-1
MTHU008880
Code-2
Prior
UMLS CUI-2
C0332152
SNOMED CT-2
288556008
Code-3
Operative Surgical Procedures
UMLS CUI-3
C0543467
SNOMED CT-3
387713003
MedDRA-3
10042609
LOINC-3
MTHU007597
Operation
Descrição

Operation

Anzahl Operationen
Descrição

wievielter mammachirurgischer Eingriff während dieses Aufenthaltes

Tipo de dados

integer

Alias
Code-1
Count of entities (property) (qualifier value)
UMLS CUI-1
C0449788
SNOMED CT-1
410681005
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Code-3
Hospitalization)
UMLS CUI-3
C0019993
SNOMED CT-3
394656005
MedDRA-3
10054112
Prä-Biopsie Drahtmarkierung
Descrição

präoperative Drahtmarkierung gesteuert durch bildgebende Verfahren

Tipo de dados

integer

Alias
Code-1
Pre-biopsy localization of breast lesion using self retaining wire (procedure)
UMLS CUI-1
C0473516
SNOMED CT-1
237381006
Intraoperatives Präparatröntgen
Descrição

intraoperatives Präparatröntgen

Tipo de dados

boolean

Alias
Code-1
Specimen mammography (procedure)
UMLS CUI-1
C0203031
SNOMED CT-1
80865008
Code-2
Intraoperative
UMLS CUI-2
C0456904
SNOMED CT-2
277671009
Datum der OP
Descrição

OP-Datum

Tipo de dados

date

Alias
Code-1
Date in time
UMLS CUI-1
C0011008
SNOMED CT-1
410671006
LOINC-1
MTHU021546
Chirurgische und medizinische Prozeduren
Descrição

Operation

Tipo de dados

string

Alias
Code-1
Surgical and medical procedures
UMLS CUI-1
C1948041
SNOMED CT-1
71388002
LOINC-1
MTHU006237
Sentinel Lymphknoten Biopsie
Descrição

Sentinel-Lymphknoten-Biopsie bei diesem Eingriff durchgeführt

Tipo de dados

boolean

Alias
Code-1
Sentinel Lymph Node Biopsy
UMLS CUI-1
C0796693
SNOMED CT-1
396487001
Antibiotikaprophylaxe
Descrição

perioperative Antibiotikaprophylaxe

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
Code-1
antibiotics; administration, prophylactic
UMLS CUI-1
C1388076
Code-2
Perioperative
UMLS CUI-2
C1518988
Komplikation
Descrição

Komplikation

postoperative Komplikationen mit operativer Revision
Descrição

behandlungsbedürftige postoperative chirurgische Komplikationen

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
Code-1
Postoperative Complications
UMLS CUI-1
C0032787
SNOMED CT-1
385486001
MedDRA-1
10058018
Code-2
Repeated Surgical Procedure
UMLS CUI-2
C0035110
SNOMED CT-2
261554009
MedDRA-2
10038579
postoperative Wundinfektion
Descrição

Wundinfektion

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
UMLS CUI-1
CL354174
Hämatom
Descrição

Nachblutung/Hämatom

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
UMLS CUI-1
C0019080
SNOMED CT-1
131148009
MedDRA-1
10005103
ICD-10-CM-1
R58
ICD-9-CM-1
459.0
Serom
Descrição

Serom

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
Code-1
Postoperative seroma (disorder)
UMLS CUI-1
C1998103
SNOMED CT-1
429494008
Sonstiges
Descrição

sonstige

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
UMLS CUI-1
C0205394
SNOMED CT-1
74964007
Code-2
Complication
UMLS CUI-2
C0009566
SNOMED CT-2
116223007
LOINC-2
MTHU008883
Histologie
Descrição

Histologie unter Berücksichtigung der Vorbefunde

Tipo de dados

integer

Alias
Code-1
Histopathology
UMLS CUI-1
C0677043
SNOMED CT-1
394597005
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Histologie-Code ICD-0-3
Descrição

maligne Neoplasie

Tipo de dados

string

Alias
Code-1
ICDO3 Morphology Axis
UMLS CUI-1
CL364362
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
abgeschlossene Primärtherapie
Descrição

primär-operative Therapie abgeschlossen

Tipo de dados

boolean

Alias
Code-1
Complete (qualifier value)
UMLS CUI-1
C0205197
SNOMED CT-1
255594003
Code-2
Primal therapy (regime/therapy)
UMLS CUI-2
C0221296
SNOMED CT-2
439741009
andere Empfehlung
Descrição

weitere Therapieempfehlung

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
Code-1
Advising
UMLS CUI-1
C1828381
SNOMED CT-1
424900004
Code-2
Other
UMLS CUI-2
C0205394
SNOMED CT-2
74964007
Revisionsoperation
Descrição

1 = Empfehlung zur Nachresektion

Tipo de dados

boolean

Alias
Code-Info
changed_datatype
UMLS CUI-1
C0035110
SNOMED CT-1
261554009
MedDRA-1
10038579
Code-2
Plan
UMLS CUI-2
C1301732
SNOMED CT-2
397943006
Mastektomie
Descrição

2 = Empfehlung zur Mastektomie

Tipo de dados

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
Sentinel Lymphknoten Biopsie
Descrição

3 = Empfehlung zur Sentinel-Lymphknoten-Biopsie

Tipo de dados

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
Descrição

4 = Empfehlung zur Axilladissektion

Tipo de dados

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
Brusterhaltende Therapie
Descrição

6 = Empfehlung zur BET

Tipo de dados

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
pathologisches Stadium
Descrição

pathologisches Stadium

pathologisches Stadium
Descrição

pTpN

Tipo de dados

boolean

Alias
Code-Info
for_compare
Code-1
Tumor-node-metastasis (TNM) classification of malignant tumor after operation (observable entity)
UMLS CUI-1
C1264753
SNOMED CT-1
106249008
pT Stadium
Descrição

pT

Tipo de dados

string

Alias
Code-1
pT category finding (finding)
UMLS CUI-1
C1272834
SNOMED CT-1
385385001
pN Stadium
Descrição

pN

Tipo de dados

string

Alias
Code-1
pN category finding (finding)
UMLS CUI-1
C1272833
SNOMED CT-1
385381005
Anzahl der untersuchten Lymphknoten
Descrição

Anzahl histologisch untersuchter regionärer Lymphknoten

Tipo de dados

integer

Alias
UMLS CUI-1
C2733494
SNOMED CT-1
444025001
Anzahl der untersuchten Lymphknoten
Descrição

Anzahl histologisch untersuchter regionärer Lymphknoten - unbekannt

Tipo de dados

boolean

Alias
UMLS CUI-1
C2733494
SNOMED CT-1
444025001
Code-2
Unknown
UMLS CUI-2
C0439673
SNOMED CT-2
261665006
Histologisches Grading
Descrição

Grading

Tipo de dados

integer

Alias
UMLS CUI-1
C0919553
SNOMED CT-1
371469007
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Tumorgröße
Descrição

Gesamttumorgröße

Tipo de dados

integer

Alias
Item-Info
mm
Code-1
Tumor size (observable entity)
UMLS CUI-1
C0475440
SNOMED CT-1
263605001
Östrogen-Rezeptor
Descrição

Östrogen (ER)

Tipo de dados

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
Descrição

Progesteron (PR)

Tipo de dados

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
Descrição

Her2/neu-Status

Tipo de dados

integer

Alias
Code-1
Her2/Neu Status
UMLS CUI-1
C1512413
multilokulär
Descrição

histologisch gesicherte Multizentrizität

Tipo de dados

boolean

Alias
UMLS CUI-1
CL381556
Abstand des Tumors vom nächstgelegenen Rand
Descrição

Angaben des Pathologen zum metrischen Sicherheitsabstand

Tipo de dados

integer

Alias
Code-1
Distance of tumor from closest surgical margin (breast) (observable entity)
UMLS CUI-1
C1268956
SNOMED CT-1
373120008
Abstand des Tumors vom nächstgelegenen Rand
Descrição

geringster Abstand des Tumors zum Resektionsrand

Tipo de dados

integer

Alias
Code-1
Distance of tumor from closest surgical margin (breast) (observable entity)
UMLS CUI-1
C1268956
SNOMED CT-1
373120008
M Stadium
Descrição

Fernmetastasen M nach Vorliegen der Staging - Befunde

Tipo de dados

integer

Alias
Code-1
M Stage
UMLS CUI-1
C0456533
SNOMED CT-1
77208005
Therapie
Descrição

Therapie

brusterhaltende Therapie (BET)
Descrição

brusterhaltende Therapie (BET)

Tipo de dados

integer

Alias
Code-1
Breast Conservation Treatment
UMLS CUI-1
C0917927
Axilladissektion
Descrição

axilläre Lymphknotenentfernung ohne Markierung bei diesem oder vorausgegangenem Aufenthalt durchgeführt

Tipo de dados

boolean

Alias
Code-1
Axillary Lymph Node Dissection
UMLS CUI-1
C0193867
SNOMED CT-1
234254000
MedDRA-1
10068477
ICD-9-CM-1
40.23
Sentinel Lymphknoten Biopsie
Descrição

Sentinel-Lymphknoten-Biopsie bei diesem oder vorausgegangenem Aufenthalt durchgeführt

Tipo de dados

boolean

Alias
Code-1
Sentinel Lymph Node Biopsy
UMLS CUI-1
C0796693
SNOMED CT-1
396487001
Markierung
Descrição

Art der Markierung

Tipo de dados

integer

Alias
Code-1
Labeling
UMLS CUI-1
C1947902
Behandlungsverlauf Patient
Descrição

Behandlungsverlauf Patient

postoperativ
Descrição

postoperative Therapieplanung in interdisziplinärer Tumorkonferenz

Tipo de dados

boolean

Alias
Code-1
Post
UMLS CUI-1
C0231290
SNOMED CT-1
237679004
Code-2
Operative Surgical Procedures
UMLS CUI-2
C0543467
SNOMED CT-2
387713003
MedDRA-2
10042609
LOINC-2
MTHU007597
Tumorkonferenz
Descrição

interdisziplinäre Therapieplanung

Tipo de dados

integer

Alias
Code-Info
changed_datatype
Code-1
Cancer conference
UMLS CUI-1
C0805438
LOINC-1
MTHU010336
Code-2
Type - attribute
UMLS CUI-2
C0332307
SNOMED CT-2
410656007
LOINC-2
MTHU013727
Gespräch mit Patient über Tumorkonferenzentscheidung
Descrição

postoperative Therapieplanung mit Patientin besprochen

Tipo de dados

boolean

Alias
Code-1
Had a chat to patient (situation)
UMLS CUI-1
C0418830
SNOMED CT-1
183093006
Code-2
Cancer conference
UMLS CUI-2
C0805438
LOINC-2
MTHU010336
Code-3
Decision
UMLS CUI-3
C0679006
datum Gespräch mit Patient über Tumorkonferenzentscheidung
Descrição

Datum des Gespräches mit Patientin

Tipo de dados

date

Alias
Code-1
Had a chat to patient (situation)
UMLS CUI-1
C0418830
SNOMED CT-1
183093006
Code-2
Cancer conference
UMLS CUI-2
C0805438
LOINC-2
MTHU010336
Code-3
Decision
UMLS CUI-3
C0679006
Code-4
Date in time
UMLS CUI-4
C0011008
SNOMED CT-4
410671006
LOINC-4
MTHU021546
Meldung Krebsregister
Descrição

Erfolgte Meldung an epidemiologische Landeskrebsregister der klinisches Krebsregister

Tipo de dados

boolean

Alias
Code-1
Reporting
UMLS CUI-1
C0700287
SNOMED CT-1
223458004
LOINC-1
MTHU002737
Code-2
Cancer Registry
UMLS CUI-2
C0805443
LOINC-2
MTHU010262
Patienten Entlassung
Descrição

Patienten Entlassung

Entlassungsdatum Krankenhaus
Descrição

Entlassungsdatum Krankenhaus

Tipo de dados

date

Alias
Code-1
Discharge from hospital (procedure)
UMLS CUI-1
C0586003
SNOMED CT-1
308283009
Code-2
Date in time
UMLS CUI-2
C0011008
SNOMED CT-2
410671006
LOINC-2
MTHU021546
Entlassungsdiagnose
Descrição

Entlassungsdiagnose

Tipo de dados

integer

Alias
Code-1
discharge diagnosis - ActCode
UMLS CUI-1
C1555319
Grund für Entlassung
Descrição

Entlassungsgrund

Tipo de dados

integer

Alias
Code-1
Indication of (contextual qualifier)
UMLS CUI-1
C0392360
SNOMED CT-1
410666004
LOINC-1
MTHU008862
Code-2
Discharge from hospital (procedure)
UMLS CUI-2
C0586003
SNOMED CT-2
308283009
Autopsie
Descrição

Sektion erfolgt

Tipo de dados

boolean

Alias
Code-1
Autopsy
UMLS CUI-1
C0004398
SNOMED CT-1
29240004
MedDRA-1
10050117
ICD-10-CM-1
89.8

Similar models

quality management

  1. StudyEvent: quality management
    1. quality management
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Mammachirurgie
Item Group
Basis
Institutionskennzeichen
Item
Identifikationsnummer der Meldequelle
string
Registration Authority (Code-1)
C2699022 (UMLS CUI-1)
Betriebstätten-Nr
Item
nicht_sinnvoll_für_Untersuchung
integer
Fachabteilung
Item
Institution
integer
C0021622 (UMLS CUI-1)
Identifikationsnummer der Patientin
Item
Identifikationsnummer der Patientin
integer
Patients (Code-1)
C0030705 (UMLS CUI-1)
116154003 (SNOMED CT-1)
Identification number (Code-2)
C1300638 (UMLS CUI-2)
396278008 (SNOMED CT-2)
Geburtsdatum
Item
Patienten-Geburtsdatum
date
C0421451 (UMLS CUI-1)
184099003 (SNOMED CT-1)
Item
Patienten-Geschlecht
integer
C0150831 (UMLS CUI-1)
184100006 (SNOMED CT-1)
Code List
Patienten-Geschlecht
CL Item
männlich (1 = männlich)
C0086582 (UMLS CUI-1)
10052007 (SNOMED CT-1)
CL Item
weiblich (2 = weiblich)
C0086287 (UMLS CUI-1)
1086007 (SNOMED CT-1)
Aufnahmedatum Krankenhaus
Item
Aufnahmedatum
date
Date of admission (Code-1)
C1302393 (UMLS CUI-1)
399423000 (SNOMED CT-1)
MTHU029790 (LOINC-1)
Aufnahmediagnose
Item
Aufnahmediagnose
string
ADMITTING DIAGNOSIS (Code-1)
C0332133 (UMLS CUI-1)
52870002 (SNOMED CT-1)
Item
ASA
integer
Finding of American Society of Anesthesiologists physical status classification (finding) (Code-1)
C1531480 (UMLS CUI-1)
413347006 (SNOMED CT-1)
CL Item
ASA Status 1 (1)
American Society of Anesthesiologists physical status class 1 (finding) (Code-1)
C1531504 (UMLS CUI-1)
413495001 (SNOMED CT-1)
CL Item
ASA Status 2 (2)
American Society of Anesthesiologists physical status class 2 (finding) (Code-1)
C1531505 (UMLS CUI-1)
413496000 (SNOMED CT-1)
CL Item
ASA Status 3 (3)
American Society of Anesthesiologists physical status class 3 (finding) (Code-1)
C1531506 (UMLS CUI-1)
413497009 (SNOMED CT-1)
CL Item
ASA Status 4 (4)
American Society of Anesthesiologists physical status class 4 (finding) (Code-1)
C1531507 (UMLS CUI-1)
413498004 (SNOMED CT-1)
CL Item
ASA Status 5 (5)
American Society of Anesthesiologists physical status class 5 (finding) (Code-1)
C1531508 (UMLS CUI-1)
413499007 (SNOMED CT-1)
Item Group
Brust
Item
Körperseite
integer
C0441987 (UMLS CUI-1)
182353008 (SNOMED CT-1)
MTHU014973 (LOINC-1)
Tumor site (Code-2)
C0475445 (UMLS CUI-2)
263591006 (SNOMED CT-2)
MTHU015562 (LOINC-2)
Code List
Körperseite
CL Item
rechts (1 = rechts)
C0205090 (UMLS CUI-1)
24028007 (SNOMED CT-1)
CL Item
links (2 = links)
C0205091 (UMLS CUI-1)
7771000 (SNOMED CT-1)
Item
Stadium
integer
Stage (Code-1)
C1300072 (UMLS CUI-1)
371508000 (SNOMED CT-1)
Code List
Stadium
CL Item
Primärtumor (1 = Primärerkrankung)
Primary Malignant Neoplasm (Code-1)
C1306459 (UMLS CUI-1)
372087000 (SNOMED CT-1)
CL Item
lokal-rezidiviert (2 = lokoregionäres Rezidiv nach BET)
Neoplasm Recurrence, Local (Code-1)
C0027643 (UMLS CUI-1)
Breast Conservation Treatment (Code-2)
C0917927 (UMLS CUI-2)
CL Item
lokal-rezidiviert (3 = lokoregionäres Rezidiv nach Mastektomie)
Neoplasm Recurrence, Local (Code-1)
C0027643 (UMLS CUI-1)
Mastectomy (Code-2)
C0024881 (UMLS CUI-2)
10026878 (MedDRA-2)
85.4 (ICD-9-CM-2)
Aufnahme zum ersten offenen Eingriff an dieser Brust wegen Primärerkrankung
Item
Erste Operation - Primärtumor
boolean
First (Code-1)
C0205435 (UMLS CUI-1)
255216001 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
Primary Malignant Neoplasm (Code-3)
C1306459 (UMLS CUI-3)
372087000 (SNOMED CT-3)
tastbarer Mammabefund
Item
Tastbarer Mamma-Befund
boolean
Palpatory diagnosis (qualifier value) (Code-1)
C1562881 (UMLS CUI-1)
416400009 (SNOMED CT-1)
Breast (Code-2)
C0006141 (UMLS CUI-2)
76752008 (SNOMED CT-2)
MTHU011382 (LOINC-2)
Item
Grund des Arztbesuches
integer
Reason for patient visit (Code-1)
C1704447 (UMLS CUI-1)
103324002 (SNOMED CT-1)
MTHU013910 (LOINC-1)
Code List
Grund des Arztbesuches
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
Selbstuntersuchung (Selbstuntersuchung)
C0080142 (UMLS CUI-1)
409978001 (SNOMED CT-1)
CL Item
Krebs-Screeninguntersuchung (Früherkennung)
C0199230 (UMLS CUI-1)
15886004 (SNOMED CT-1)
CL Item
Screening (Mammografie-Screening)
C0220908 (UMLS CUI-1)
275926002 (SNOMED CT-1)
CL Item
Tumorsymptome (Tumorsymptomatik)
Symptoms (Code-1)
C1457887 (UMLS CUI-1)
MTHU021540 (LOINC-1)
780-789,99 (ICD-9-CM-1)
Malignant Neoplasms (Code-2)
C0006826 (UMLS CUI-2)
363346000 (SNOMED CT-2)
10007050 (MedDRA-2)
MTHU010328 (LOINC-2)
C80 (ICD-10-CM-2)
199 (ICD-9-CM-2)
CL Item
Nachsorge (Nachsorge)
C0001758 (UMLS CUI-1)
413467001 (SNOMED CT-1)
CL Item
nicht näher bezeichnete Untersuchung (sonstiges)
C0260880 (UMLS CUI-1)
V72.9 (ICD-9-CM-1)
prätherapeutische histologische Diagnostik
Item
prätherapeutischer histologischer Befund
boolean
Histological finding (Code-1)
C0449575 (UMLS CUI-1)
263540008 (SNOMED CT-1)
Prior (Code-2)
C0332152 (UMLS CUI-2)
288556008 (SNOMED CT-2)
Therapeutic procedure (Code-3)
C0087111 (UMLS CUI-3)
277132007 (SNOMED CT-3)
10053757 (MedDRA-3)
MTHU008880 (LOINC-3)
Item
Histologie
integer
Histologic Type (Code-1)
C0449574 (UMLS CUI-1)
263541007 (SNOMED CT-1)
MTHU020048 (LOINC-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Code List
Histologie
CL Item
normales Brustgewebe (1 = nicht verwertbar oder ausschließlich Normalgewebe)
Mammary Gland Tissue (Code-1)
C1521747 (UMLS CUI-1)
CL Item
benigne (2 = benigne / entzündliche Veränderung)
Benign (Code-1)
C0205183 (UMLS CUI-1)
30807003 (SNOMED CT-1)
CL Item
unklar ob benigne oder maligne (3 = benigne, aber mit unsicherem biologischem Potential)
Neoplasm, Uncertain Whether Benign or Malignant (Code-1)
C0677041 (UMLS CUI-1)
86251006 (SNOMED CT-1)
CL Item
Malignitätsverdacht (4 = malignitätsverdächtig)
Suspected malignancy (situation) (Code-1)
C0581833 (UMLS CUI-1)
162572001 (SNOMED CT-1)
CL Item
DCIS (B5a)
extended_coding (Code-Info)
Noninfiltrating Intraductal Carcinoma (Code-1)
C0007124 (UMLS CUI-1)
86616005 (SNOMED CT-1)
10013806 (MedDRA-1)
D05.1 (ICD-10-CM-1)
CL Item
Invasive Karzinom (B5b)
extended_coding (Code-Info)
Invasive Breast Carcinoma (Code-1)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
CL Item
Tumor Invasion kann nicht beurteilt werden (B5c)
extended_coding (Code-Info)
Tumor invasion cannot be assessed (finding) (Code-1)
C1276687 (UMLS CUI-1)
370048007 (SNOMED CT-1)
CL Item
anderer Tumor (B5d)
extended_coding (Code-Info)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Malignant Neoplasms (Code-2)
C0006826 (UMLS CUI-2)
363346000 (SNOMED CT-2)
10028997 (MedDRA-2)
MTHU010328 (LOINC-2)
C00-C96 (ICD-10-CM-2)
maligne Neoplasie
Item
Histologie-Code ICD-0-3
string
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Biopsy (Code-2)
C0005558 (UMLS CUI-2)
86273004 (SNOMED CT-2)
10004720 (MedDRA-2)
MTHU028106 (LOINC-2)
Datum (Ausgang Pathologie) des prätherapeutischen histologischen Befundes
Item
Datum Pathologie Befund
date
Date of pathology report (observable entity) (Code-1)
C1302659 (UMLS CUI-1)
399737008 (SNOMED CT-1)
Item
Tumorkonferenz
integer
changed_datatype (Code-Info)
Cancer conference (Code-1)
C0805438 (UMLS CUI-1)
MTHU010336 (LOINC-1)
Type - attribute (Code-2)
C0332307 (UMLS CUI-2)
410656007 (SNOMED CT-2)
MTHU013727 (LOINC-2)
Code List
Tumorkonferenz
CL Item
prätherapeutisch (prätherapeutisch)
changed_datatype (Code-Info)
Prior (Code-1)
C0332152 (UMLS CUI-1)
288556008 (SNOMED CT-1)
Therapeutic procedure (Code-2)
C0087111 (UMLS CUI-2)
277132007 (SNOMED CT-2)
10053757 (MedDRA-2)
MTHU008880 (LOINC-2)
Datum der Therapieplanung
Item
Datum der Konferenz
date
Cancer conference:Time Stamp -- Date and Time:Point in time:Cancer.To be specified in another part of the message:Quantitative (Code-1)
C0804663 (UMLS CUI-1)
21875-0 (LOINC-1)
Item
präoperative Therapie
integer
changed_datatype (Code-Info)
Therapeutic procedure (Code-1)
C0087111 (UMLS CUI-1)
277132007 (SNOMED CT-1)
10053757 (MedDRA-1)
MTHU008880 (LOINC-1)
Prior (Code-2)
C0332152 (UMLS CUI-2)
288556008 (SNOMED CT-2)
Operative Surgical Procedures (Code-3)
C0543467 (UMLS CUI-3)
387713003 (SNOMED CT-3)
10042609 (MedDRA-3)
MTHU007597 (LOINC-3)
Code List
präoperative Therapie
CL Item
Chemotherapie (systemische Chemotherapie)
changed_datatype (Code-Info)
C0392920 (UMLS CUI-1)
69960004 (SNOMED CT-1)
10061758 (MedDRA-1)
CL Item
Hormon- / endokrine Therapie (endokrine Therapie)
changed_datatype (Code-Info)
C0279025 (UMLS CUI-1)
169413002 (SNOMED CT-1)
10065646 (MedDRA-1)
CL Item
Immuntherapie (spezifische Antikörpertherapie)
changed_datatype (Code-Info)
C0021083 (UMLS CUI-1)
76334006 (SNOMED CT-1)
CL Item
Bestrahlung (Strahlentherapie)
changed_datatype (Code-Info)
C1522449 (UMLS CUI-1)
108290001 (SNOMED CT-1)
10037794 (MedDRA-1)
CL Item
sonstige Therapie (sonstige)
changed_datatype (Code-Info)
Other Therapy (Code-1)
C0418967 (UMLS CUI-1)
Item Group
Operation
wievielter mammachirurgischer Eingriff während dieses Aufenthaltes
Item
Anzahl Operationen
integer
Count of entities (property) (qualifier value) (Code-1)
C0449788 (UMLS CUI-1)
410681005 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
Hospitalization) (Code-3)
C0019993 (UMLS CUI-3)
394656005 (SNOMED CT-3)
10054112 (MedDRA-3)
Item
Prä-Biopsie Drahtmarkierung
integer
Pre-biopsy localization of breast lesion using self retaining wire (procedure) (Code-1)
C0473516 (UMLS CUI-1)
237381006 (SNOMED CT-1)
CL Item
Mammographie (Mammographie )
Plain X-ray guided wire localization of breast lesion (procedure) (Code-1)
C1997063 (UMLS CUI-1)
428907005 (SNOMED CT-1)
CL Item
Sonographie (Sonographie)
Insertion of guide wire into breast using ultrasound guidance (procedure) (Code-1)
C2315526 (UMLS CUI-1)
433222002 (SNOMED CT-1)
CL Item
Kernspintomographie (MRT)
Magnetic resonance imaging guidance (procedure) (Code-1)
C0442974 (UMLS CUI-1)
258177008 (SNOMED CT-1)
intraoperatives Präparatröntgen
Item
Intraoperatives Präparatröntgen
boolean
Specimen mammography (procedure) (Code-1)
C0203031 (UMLS CUI-1)
80865008 (SNOMED CT-1)
Intraoperative (Code-2)
C0456904 (UMLS CUI-2)
277671009 (SNOMED CT-2)
OP-Datum
Item
Datum der OP
date
Date in time (Code-1)
C0011008 (UMLS CUI-1)
410671006 (SNOMED CT-1)
MTHU021546 (LOINC-1)
Operation
Item
Chirurgische und medizinische Prozeduren
string
Surgical and medical procedures (Code-1)
C1948041 (UMLS CUI-1)
71388002 (SNOMED CT-1)
MTHU006237 (LOINC-1)
Sentinel-Lymphknoten-Biopsie bei diesem Eingriff durchgeführt
Item
Sentinel Lymphknoten Biopsie
boolean
Sentinel Lymph Node Biopsy (Code-1)
C0796693 (UMLS CUI-1)
396487001 (SNOMED CT-1)
perioperative Antibiotikaprophylaxe
Item
Antibiotikaprophylaxe
boolean
changed_datatype (Code-Info)
antibiotics; administration, prophylactic (Code-1)
C1388076 (UMLS CUI-1)
Perioperative (Code-2)
C1518988 (UMLS CUI-2)
Item Group
Komplikation
behandlungsbedürftige postoperative chirurgische Komplikationen
Item
postoperative Komplikationen mit operativer Revision
boolean
changed_datatype (Code-Info)
Postoperative Complications (Code-1)
C0032787 (UMLS CUI-1)
385486001 (SNOMED CT-1)
10058018 (MedDRA-1)
Repeated Surgical Procedure (Code-2)
C0035110 (UMLS CUI-2)
261554009 (SNOMED CT-2)
10038579 (MedDRA-2)
Wundinfektion
Item
postoperative Wundinfektion
boolean
changed_datatype (Code-Info)
CL354174 (UMLS CUI-1)
Nachblutung/Hämatom
Item
Hämatom
boolean
changed_datatype (Code-Info)
C0019080 (UMLS CUI-1)
131148009 (SNOMED CT-1)
10005103 (MedDRA-1)
R58 (ICD-10-CM-1)
459.0 (ICD-9-CM-1)
Serom
Item
Serom
boolean
changed_datatype (Code-Info)
Postoperative seroma (disorder) (Code-1)
C1998103 (UMLS CUI-1)
429494008 (SNOMED CT-1)
sonstige
Item
Sonstiges
boolean
changed_datatype (Code-Info)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Complication (Code-2)
C0009566 (UMLS CUI-2)
116223007 (SNOMED CT-2)
MTHU008883 (LOINC-2)
Item
Histologie
integer
Histopathology (Code-1)
C0677043 (UMLS CUI-1)
394597005 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
CL Item
normales Brustgewebe (ausschließlich Normalgewebe)
Mammary Gland Tissue (Code-1)
C1521747 (UMLS CUI-1)
CL Item
benigne (benigne / entzündliche Veränderung)
Benign (Code-1)
C0205183 (UMLS CUI-1)
30807003 (SNOMED CT-1)
CL Item
unklar ob benigne oder maligne (Risikoläsion)
Neoplasm, Uncertain Whether Benign or Malignant (Code-1)
C0677041 (UMLS CUI-1)
86251006 (SNOMED CT-1)
CL Item
Malignitätsverdacht (B4)
extended_coding (Code-Info)
Suspected malignancy (situation) (Code-1)
C0581833 (UMLS CUI-1)
162572001 (SNOMED CT-1)
CL Item
DCIS (B5a)
extended_coding (Code-Info)
Noninfiltrating Intraductal Carcinoma (Code-1)
C0007124 (UMLS CUI-1)
86616005 (SNOMED CT-1)
10013806 (MedDRA-1)
D05.1 (ICD-10-CM-1)
CL Item
Invasive Karzinom (B5b)
extended_coding (Code-Info)
Invasive Breast Carcinoma (Code-1)
C0853879 (UMLS CUI-1)
10006190 (MedDRA-1)
CL Item
Tumor Invasion kann nicht beurteilt werden (B5c)
extended_coding (Code-Info)
Tumor invasion cannot be assessed (finding) (Code-1)
C1276687 (UMLS CUI-1)
370048007 (SNOMED CT-1)
CL Item
anderer Tumor (B5d)
extended_coding (Code-Info)
Other (Code-1)
C0205394 (UMLS CUI-1)
74964007 (SNOMED CT-1)
Malignant Neoplasms (Code-2)
C0006826 (UMLS CUI-2)
363346000 (SNOMED CT-2)
10028997 (MedDRA-2)
MTHU010328 (LOINC-2)
C00-C96 (ICD-10-CM-2)
maligne Neoplasie
Item
Histologie-Code ICD-0-3
string
ICDO3 Morphology Axis (Code-1)
CL364362 (UMLS CUI-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
primär-operative Therapie abgeschlossen
Item
abgeschlossene Primärtherapie
boolean
Complete (qualifier value) (Code-1)
C0205197 (UMLS CUI-1)
255594003 (SNOMED CT-1)
Primal therapy (regime/therapy) (Code-2)
C0221296 (UMLS CUI-2)
439741009 (SNOMED CT-2)
weitere Therapieempfehlung
Item
andere Empfehlung
boolean
changed_datatype (Code-Info)
Advising (Code-1)
C1828381 (UMLS CUI-1)
424900004 (SNOMED CT-1)
Other (Code-2)
C0205394 (UMLS CUI-2)
74964007 (SNOMED CT-2)
1 = Empfehlung zur Nachresektion
Item
Revisionsoperation
boolean
changed_datatype (Code-Info)
C0035110 (UMLS CUI-1)
261554009 (SNOMED CT-1)
10038579 (MedDRA-1)
Plan (Code-2)
C1301732 (UMLS CUI-2)
397943006 (SNOMED CT-2)
2 = Empfehlung zur Mastektomie
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)
3 = Empfehlung zur Sentinel-Lymphknoten-Biopsie
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)
4 = Empfehlung zur Axilladissektion
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)
6 = Empfehlung zur 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)
Item Group
pathologisches Stadium
pTpN
Item
pathologisches Stadium
boolean
for_compare (Code-Info)
Tumor-node-metastasis (TNM) classification of malignant tumor after operation (observable entity) (Code-1)
C1264753 (UMLS CUI-1)
106249008 (SNOMED CT-1)
pT
Item
pT Stadium
string
pT category finding (finding) (Code-1)
C1272834 (UMLS CUI-1)
385385001 (SNOMED CT-1)
pN
Item
pN Stadium
string
pN category finding (finding) (Code-1)
C1272833 (UMLS CUI-1)
385381005 (SNOMED CT-1)
Anzahl histologisch untersuchter regionärer Lymphknoten
Item
Anzahl der untersuchten Lymphknoten
integer
C2733494 (UMLS CUI-1)
444025001 (SNOMED CT-1)
Anzahl histologisch untersuchter regionärer Lymphknoten - unbekannt
Item
Anzahl der untersuchten Lymphknoten
boolean
C2733494 (UMLS CUI-1)
444025001 (SNOMED CT-1)
Unknown (Code-2)
C0439673 (UMLS CUI-2)
261665006 (SNOMED CT-2)
Item
Histologisches Grading
integer
C0919553 (UMLS CUI-1)
371469007 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
Code List
Histologisches Grading
CL Item
G1 (G1)
G1 grade (finding) (Code-1)
C0475269 (UMLS CUI-1)
54102005 (SNOMED CT-1)
CL Item
G2 (G2)
G2 grade (finding) (Code-1)
C0475270 (UMLS CUI-1)
1663004 (SNOMED CT-1)
CL Item
G3 (G3)
G3 grade (finding) (Code-1)
C0475271 (UMLS CUI-1)
61026006 (SNOMED CT-1)
CL Item
X = Differenzierungsgrad kann nicht bestimmt werden (GX)
Grade cannot be determined (finding) (Code-1)
C1273714 (UMLS CUI-1)
384741006 (SNOMED CT-1)
Gesamttumorgröße
Item
Tumorgröße
integer
mm (Item-Info)
Tumor size (observable entity) (Code-1)
C0475440 (UMLS CUI-1)
263605001 (SNOMED CT-1)
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)
Code List
Östrogen-Rezeptor
CL Item
schwach positiv (schwach positiv)
Weakly positive (qualifier value) (Code-1)
C0442730 (UMLS CUI-1)
260408008 (SNOMED CT-1)
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
unbekannt (unbekannt)
Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
CL Item
only_in_connection_with_ER (only_in_connection_with_ER)
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)
Code List
Progesteron-Rezeptor
CL Item
schwach positiv (schwach positiv)
Weakly positive (qualifier value) (Code-1)
C0442730 (UMLS CUI-1)
260408008 (SNOMED CT-1)
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
unbekannt (unbekannt)
Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
CL Item
only_in_connection_with_ER (only_in_connection_with_ER)
Item
Her-2/neu
integer
Her2/Neu Status (Code-1)
C1512413 (UMLS CUI-1)
Code List
Her-2/neu
CL Item
negativ (0 = negativ)
HER2-negative breast cancer (Code-1)
CL412283 (UMLS CUI-1)
CL Item
positiv (1 = positiv)
HER2-positive carcinoma of breast (disorder) (Code-1)
C1960398 (UMLS CUI-1)
427685000 (SNOMED CT-1)
CL Item
unbekannt (9 = unbekannt)
Unknown (Code-1)
C0439673 (UMLS CUI-1)
261665006 (SNOMED CT-1)
histologisch gesicherte Multizentrizität
Item
multilokulär
boolean
CL381556 (UMLS CUI-1)
Item
Abstand des Tumors vom nächstgelegenen Rand
integer
Distance of tumor from closest surgical margin (breast) (observable entity) (Code-1)
C1268956 (UMLS CUI-1)
373120008 (SNOMED CT-1)
Code List
Abstand des Tumors vom nächstgelegenen Rand
CL Item
Nein (0 = nein)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Ja (1 = ja)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
Vollremission - neoadjuvante Therape (2 = Vollremission nach neoadjuvanter Therapie)
In complete remission (Code-1)
C0677874 (UMLS CUI-1)
103338009 (SNOMED CT-1)
Neo-adjuvant - intent (qualifier value) (Code-2)
C1298676 (UMLS CUI-2)
373847000 (SNOMED CT-2)
Therapeutic procedure (Code-3)
C0087111 (UMLS CUI-3)
277132007 (SNOMED CT-3)
10053757 (MedDRA-3)
MTHU008880 (LOINC-3)
geringster Abstand des Tumors zum Resektionsrand
Item
Abstand des Tumors vom nächstgelegenen Rand
integer
Distance of tumor from closest surgical margin (breast) (observable entity) (Code-1)
C1268956 (UMLS CUI-1)
373120008 (SNOMED CT-1)
Fernmetastasen M nach Vorliegen der Staging - Befunde
Item
M Stadium
integer
M Stage (Code-1)
C0456533 (UMLS CUI-1)
77208005 (SNOMED CT-1)
Item Group
Therapie
Item
brusterhaltende Therapie (BET)
integer
Breast Conservation Treatment (Code-1)
C0917927 (UMLS CUI-1)
Code List
brusterhaltende Therapie (BET)
CL Item
Nein (0 = nein)
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
CL Item
Ja (1 = ja)
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
CL Item
Nein (2 = nein (auf Wunsch Patient(in) trotz erfültter Kriterien BET))
C1298908 (UMLS CUI-1)
373067005 (SNOMED CT-1)
desire (Code-2)
C0871633 (UMLS CUI-2)
CL Item
Ja (2 = ja (auf Wunsch Patient(in) trotz erfültter Kriterien BET))
C1298907 (UMLS CUI-1)
373066001 (SNOMED CT-1)
desire (Code-2)
C0871633 (UMLS CUI-2)
axilläre Lymphknotenentfernung ohne Markierung bei diesem oder vorausgegangenem Aufenthalt durchgeführt
Item
Axilladissektion
boolean
Axillary Lymph Node Dissection (Code-1)
C0193867 (UMLS CUI-1)
234254000 (SNOMED CT-1)
10068477 (MedDRA-1)
40.23 (ICD-9-CM-1)
Sentinel-Lymphknoten-Biopsie bei diesem oder vorausgegangenem Aufenthalt durchgeführt
Item
Sentinel Lymphknoten Biopsie
boolean
Sentinel Lymph Node Biopsy (Code-1)
C0796693 (UMLS CUI-1)
396487001 (SNOMED CT-1)
Item
Markierung
integer
Labeling (Code-1)
C1947902 (UMLS CUI-1)
Code List
Markierung
CL Item
Radionuklidmarkierung (Radionuklidmarkierung)
Radioisotopic Labeling (Code-1)
C2347885 (UMLS CUI-1)
CL Item
Farbmarkierung (Farbmarkierung)
Labeling (Code-1)
C1947902 (UMLS CUI-1)
Color (Code-2)
C0009393 (UMLS CUI-2)
MTHU001566 (LOINC-2)
Item Group
Behandlungsverlauf Patient
postoperative Therapieplanung in interdisziplinärer Tumorkonferenz
Item
postoperativ
boolean
Post (Code-1)
C0231290 (UMLS CUI-1)
237679004 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
Item
Tumorkonferenz
integer
changed_datatype (Code-Info)
Cancer conference (Code-1)
C0805438 (UMLS CUI-1)
MTHU010336 (LOINC-1)
Type - attribute (Code-2)
C0332307 (UMLS CUI-2)
410656007 (SNOMED CT-2)
MTHU013727 (LOINC-2)
Code List
Tumorkonferenz
CL Item
postoperativ (postoperative)
Post (Code-1)
C0231290 (UMLS CUI-1)
237679004 (SNOMED CT-1)
Operative Surgical Procedures (Code-2)
C0543467 (UMLS CUI-2)
387713003 (SNOMED CT-2)
10042609 (MedDRA-2)
MTHU007597 (LOINC-2)
postoperative Therapieplanung mit Patientin besprochen
Item
Gespräch mit Patient über Tumorkonferenzentscheidung
boolean
Had a chat to patient (situation) (Code-1)
C0418830 (UMLS CUI-1)
183093006 (SNOMED CT-1)
Cancer conference (Code-2)
C0805438 (UMLS CUI-2)
MTHU010336 (LOINC-2)
Decision (Code-3)
C0679006 (UMLS CUI-3)
Datum des Gespräches mit Patientin
Item
datum Gespräch mit Patient über Tumorkonferenzentscheidung
date
Had a chat to patient (situation) (Code-1)
C0418830 (UMLS CUI-1)
183093006 (SNOMED CT-1)
Cancer conference (Code-2)
C0805438 (UMLS CUI-2)
MTHU010336 (LOINC-2)
Decision (Code-3)
C0679006 (UMLS CUI-3)
Date in time (Code-4)
C0011008 (UMLS CUI-4)
410671006 (SNOMED CT-4)
MTHU021546 (LOINC-4)
Erfolgte Meldung an epidemiologische Landeskrebsregister der klinisches Krebsregister
Item
Meldung Krebsregister
boolean
Reporting (Code-1)
C0700287 (UMLS CUI-1)
223458004 (SNOMED CT-1)
MTHU002737 (LOINC-1)
Cancer Registry (Code-2)
C0805443 (UMLS CUI-2)
MTHU010262 (LOINC-2)
Item Group
Patienten Entlassung
Entlassungsdatum Krankenhaus
Item
Entlassungsdatum Krankenhaus
date
Discharge from hospital (procedure) (Code-1)
C0586003 (UMLS CUI-1)
308283009 (SNOMED CT-1)
Date in time (Code-2)
C0011008 (UMLS CUI-2)
410671006 (SNOMED CT-2)
MTHU021546 (LOINC-2)
Entlassungsdiagnose
Item
Entlassungsdiagnose
integer
discharge diagnosis - ActCode (Code-1)
C1555319 (UMLS CUI-1)
Item
Grund für Entlassung
integer
Indication of (contextual qualifier) (Code-1)
C0392360 (UMLS CUI-1)
410666004 (SNOMED CT-1)
MTHU008862 (LOINC-1)
Discharge from hospital (procedure) (Code-2)
C0586003 (UMLS CUI-2)
308283009 (SNOMED CT-2)
Code List
Grund für Entlassung
CL Item
reguläre Therapieende (Behandlung regulär beendet )
Regular (Code-1)
C0449581 (UMLS CUI-1)
17854005 (SNOMED CT-1)
End (Code-2)
C1272693 (UMLS CUI-2)
385656004 (SNOMED CT-2)
Therapeutic procedure (Code-3)
C0087111 (UMLS CUI-3)
277132007 (SNOMED CT-3)
10053757 (MedDRA-3)
MTHU008880 (LOINC-3)
CL Item
nicht_sinnvoll_für_Untersuchung (Behandlung regulär beendet, nachstationäre Behandlung vorgesehen )
CL Item
nicht_sinnvoll_für_Untersuchung (Behandlung aus sonstigen Gründen beendet )
Sektion erfolgt
Item
Autopsie
boolean
Autopsy (Code-1)
C0004398 (UMLS CUI-1)
29240004 (SNOMED CT-1)
10050117 (MedDRA-1)
89.8 (ICD-10-CM-1)

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