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ID

6459

Descrição

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

Palavras-chave

  1. 15/05/2013 15/05/2013 -
  2. 23/12/2014 23/12/2014 - Martin Dugas
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23 de dezembro de 2014

DOI

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Creative Commons BY-NC 3.0 Legacy

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    EHR breast cancer

    EHR breast cancer

    1. StudyEvent: HIS
      1. EHR breast cancer
    Patientenaufkleber groß
    Descrição

    Patientenaufkleber groß

    Alias
    UMLS CUI-1
    C1320722
    Admission date
    Descrição

    Admission date

    Tipo de dados

    date

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

    Patient ID

    Tipo de dados

    integer

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

    Gender

    Tipo de dados

    text

    Alias
    SNOMED CT-1
    184100006
    UMLS CUI-1
    C0150831
    Patient surname
    Descrição

    Last name

    Tipo de dados

    text

    Alias
    SNOMED CT-1
    184096005
    UMLS CUI-1
    C1301584
    Patient forename
    Descrição

    First name

    Tipo de dados

    text

    Alias
    SNOMED CT-1
    184095009
    UMLS CUI-1
    C1443235
    Patient date of birth
    Descrição

    Date of Birth

    Tipo de dados

    date

    Alias
    SNOMED CT-1
    184099003
    UMLS CUI-1
    C0421451
    Admission hour
    Descrição

    Admission time

    Tipo de dados

    time

    Alias
    Code-1
    Date of admission
    SNOMED CT-1
    399423000
    LOINC-1
    MTHU029790
    Code-2
    Hour
    SNOMED CT-2
    258702006
    HL7 V3-2
    HR
    UMLS CUI-1
    C2215405
    Physician admission
    Descrição

    Referring physician

    Tipo de dados

    text

    Alias
    Code-1
    Admission
    Code-2
    Physicians
    SNOMED CT-2
    112247003
    LOINC-2
    MTHU010489
    HL7 V3-2
    PHYS
    UMLS CUI-1
    C1709880
    Assessment date
    Tipo de dados

    date

    Alias
    UMLS CUI-1
    C2985720
    Anamnesebogen
    Descrição

    Anamnesebogen

    Alias
    UMLS CUI-1
    C0262926
    Responsible Person for medical case
    Descrição

    Anamnese erhoben durch

    Tipo de dados

    string

    Alias
    Code-1
    Responsible Person
    UMLS CUI-1
    C1273518
    SNOMED CT-1
    394851003
    Code-2
    Medical History
    UMLS CUI-2
    C0262926
    SNOMED CT-2
    417662000
    LOINC-2
    MTHU027722
    Referring Physician
    Descrição

    Zuweisender Arzt

    Tipo de dados

    string

    Alias
    Code-1
    Referring Physician
    UMLS CUI-1
    C1709880
    Gynecologist
    Descrição

    FFA

    Tipo de dados

    string

    Alias
    Code-1
    Gynecologist
    UMLS CUI-1
    C0237419
    SNOMED CT-1
    83685006
    HL7 V3-1
    207VG0400X
    Reason for Referring
    Descrição

    Überweisungsgrund

    Tipo de dados

    string

    Alias
    Code-1
    Referring
    UMLS CUI-1
    C0205543
    Code-2
    Indication of (contextual qualifier)
    UMLS CUI-2
    C0392360
    SNOMED CT-2
    410666004
    LOINC-2
    MTHU008862
    Reason for patient visit
    Descrição

    Grund des Arztbesuches

    Tipo de dados

    integer

    Alias
    Code-1
    Reason for patient visit
    UMLS CUI-1
    C1704447
    SNOMED CT-1
    103324002
    LOINC-1
    MTHU013910
    Medical History
    Descrição

    Anamnese

    Tipo de dados

    string

    Alias
    Code-1
    Medical History
    UMLS CUI-1
    C0262926
    SNOMED CT-1
    417662000
    LOINC-1
    MTHU027722
    Menopause Status
    Descrição

    Menopausenstatus

    Tipo de dados

    integer

    Alias
    Code-1
    Menopause finding (finding)
    UMLS CUI-1
    C0455962
    SNOMED CT-1
    276477006
    quantity of pregnancy
    Descrição

    Schwangerschaften

    Tipo de dados

    integer

    Alias
    Code-1
    Finding of quantity of pregnancy (finding)
    UMLS CUI-1
    C0566634
    SNOMED CT-1
    289204008
    Months of breast feeding
    Descrição

    Stillzeit (Monate)

    Tipo de dados

    integer

    Alias
    Code-1
    Months of breast feeding
    UMLS CUI-1
    C3172259
    Drugs
    Descrição

    Akuelle Medikamente

    Tipo de dados

    integer

    Alias
    Code-1
    Pharmaceutical Preparations
    UMLS CUI-1
    C0013227
    SNOMED CT-1
    410942007
    Contraceptives
    Descrição

    Pille

    Tipo de dados

    boolean

    Alias
    Code-1
    Contraceptives, Oral
    UMLS CUI-1
    C0009905
    SNOMED CT-1
    423938009
    Hormone replacement therapy
    Descrição

    HRT

    Tipo de dados

    boolean

    Alias
    Code-1
    Hormone replacement therapy
    UMLS CUI-1
    C0282402
    SNOMED CT-1
    266717002
    MedDRA-1
    10020388
    Aspirin
    Descrição

    ASS

    Tipo de dados

    boolean

    Alias
    Code-1
    Aspirin
    UMLS CUI-1
    C0004057
    SNOMED CT-1
    387458008
    Phenprocoumon
    Descrição

    Marcumar

    Tipo de dados

    boolean

    Alias
    Code-1
    Phenprocoumon
    UMLS CUI-1
    C0031444
    SNOMED CT-1
    59488002
    LOINC-1
    MTHU016364
    Allergic Reaction
    Descrição

    Allergien

    Tipo de dados

    string

    Alias
    Code-1
    Allergic Reaction
    UMLS CUI-1
    C1527304
    SNOMED CT-1
    106190000
    MedDRA-1
    10020751
    ICD-10-CM-1
    T78.40
    CTCAE-1
    E11248
    HL7 V3-1
    ALG
    Tobacco smoking
    Descrição

    Nikotin

    Tipo de dados

    boolean

    Alias
    Code-1
    Tobacco smoking behavior
    UMLS CUI-1
    C0453996
    SNOMED CT-1
    365981007
    How many cigarettes per day do, or did, you smoke
    Descrição

    Zig./die

    Tipo de dados

    integer

    Alias
    Code-1
    How many cigarettes per day do, or did, you smoke
    UMLS CUI-1
    C3169451
    LOINC-1
    MTHU037005
    Alcohol consumption
    Descrição

    Alkohol

    Tipo de dados

    boolean

    Alias
    Code-1
    Alcohol consumption
    UMLS CUI-1
    C0001948
    SNOMED CT-1
    160573003
    MedDRA-1
    10048921
    Details of drinking behavior
    Descrição

    Alkohol

    Tipo de dados

    string

    Alias
    Code-1
    Details of drinking behavior
    UMLS CUI-1
    C1285666
    SNOMED CT-1
    363905002
    Family history
    Tipo de dados

    text

    Alias
    UMLS CUI-1
    C0241889
    Pre-existing Condition
    Descrição

    Pre-existing Condition

    Pre-existing Condition
    Descrição

    Vorerkrankungen/Voroperationen

    Tipo de dados

    boolean

    Alias
    Code-1
    Pre-existing Condition
    UMLS CUI-1
    C0521987
    SNOMED CT-1
    102478008
    Thrombosis
    Descrição

    Thrombose

    Tipo de dados

    boolean

    Alias
    Code-1
    Thrombosis
    UMLS CUI-1
    C0040053
    SNOMED CT-1
    439127006
    MedDRA-1
    10043607
    Pre-existing Condition
    Descrição

    Erkrankungen/Operationen

    Tipo de dados

    string

    Alias
    Code-1
    Pre-existing Condition
    UMLS CUI-1
    C0521987
    SNOMED CT-1
    102478008
    Date pre-existing condition
    Descrição

    Datum/Jahr

    Tipo de dados

    date

    Alias
    Code-1
    Date in time
    UMLS CUI-1
    C0011008
    SNOMED CT-1
    410671006
    LOINC-1
    MTHU021546
    Code-2
    Pre-existing Condition
    UMLS CUI-2
    C0521987
    SNOMED CT-2
    102478008
    therapy
    Descrição

    Therapie

    Tipo de dados

    string

    Alias
    Code-1
    Therapeutic procedure
    UMLS CUI-1
    C0087111
    SNOMED CT-1
    277132007
    MedDRA-1
    10053757
    LOINC-1
    MTHU008880
    Code-2
    Pre-existing Condition
    UMLS CUI-2
    C0521987
    SNOMED CT-2
    102478008
    External Result
    Descrição

    External Result

    Mammography
    Descrição

    Mammografie

    Tipo de dados

    boolean

    Alias
    Code-1
    Mammography
    UMLS CUI-1
    C0024671
    SNOMED CT-1
    71651007
    MedDRA-1
    10026735
    Date Mammography
    Descrição

    Mammografie

    Tipo de dados

    date

    Alias
    Code-1
    Mammography
    UMLS CUI-1
    C0024671
    SNOMED CT-1
    71651007
    MedDRA-1
    10026735
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    Site of finding
    Descrição

    Seite Befund

    Tipo de dados

    integer

    Alias
    Code-Info
    for_compare
    Code-1
    Side
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Imaging, Medical
    UMLS CUI-2
    C0025086
    BI-RADS mammo
    Descrição

    BIRADS

    Tipo de dados

    integer

    Alias
    Code-Info
    merged_coding
    Code-1
    set of BI-RADS mammo terms
    UMLS CUI-1
    CL426926
    Sonography
    Descrição

    Sonografie

    Tipo de dados

    boolean

    Alias
    Code-1
    Ultrasonography, Mammary
    UMLS CUI-1
    C0080264
    SNOMED CT-1
    47079000
    Date Sonography
    Descrição

    Sonografie

    Tipo de dados

    date

    Alias
    Code-1
    Ultrasonography, Mammary
    UMLS CUI-1
    C0080264
    SNOMED CT-1
    47079000
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    BI-RADS ultrasound
    Descrição

    BIRADSanalog

    Tipo de dados

    integer

    Alias
    Code-Info
    merged_coding
    Code-1
    set of BI-RADS ultrasound terms
    UMLS CUI-1
    CL426924
    Magnetic Resonance Imaging of breast
    Descrição

    MR-MG

    Tipo de dados

    boolean

    Alias
    Code-1
    Magnetic resonance imaging of breast (procedure)
    UMLS CUI-1
    C0344104
    SNOMED CT-1
    241615005
    date Magnetic Resonance Imaging of breast
    Descrição

    MR-MG

    Tipo de dados

    date

    Alias
    Code-1
    Magnetic resonance imaging of breast (procedure)
    UMLS CUI-1
    C0344104
    SNOMED CT-1
    241615005
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    BI-RADS MRI
    Descrição

    MR-BIRADS

    Tipo de dados

    integer

    Alias
    Code-1
    set of BI-RADS MRI terms
    UMLS CUI-1
    CL426925
    Histopathology
    Descrição

    Histologie

    Tipo de dados

    boolean

    Alias
    Code-1
    Histopathology
    UMLS CUI-1
    C0677043
    SNOMED CT-1
    394597005
    other result
    Descrição

    Sonstiges

    Tipo de dados

    boolean

    Alias
    Code-1
    Other
    UMLS CUI-1
    C0205394
    SNOMED CT-1
    74964007
    Code-2
    Result
    UMLS CUI-2
    C1274040
    SNOMED CT-2
    394617004
    Physical Examination
    Descrição

    Physical Examination

    Breast size
    Descrição

    Körbchengröße

    Tipo de dados

    integer

    Alias
    Code-1
    Breast size (observable entity)
    UMLS CUI-1
    C0425782
    SNOMED CT-1
    248808008
    Ptosis of breast
    Descrição

    Ptosis

    Tipo de dados

    integer

    Alias
    Code-1
    Ptosis of breast
    UMLS CUI-1
    C2233848
    ICD-10-CM-1
    N64.81
    ICD-9-CM-1
    611.81
    Symmetry
    Descrição

    Symmetrie

    Tipo de dados

    integer

    Alias
    Code-1
    Symmetry of breasts (observable entity)
    UMLS CUI-1
    C0425778
    nipple discharge
    Descrição

    Sekretion

    Tipo de dados

    integer

    Alias
    Code-1
    nipple discharge
    UMLS CUI-1
    C0149741
    SNOMED CT-1
    54302000
    MedDRA-1
    10006223
    LOINC-1
    MTHU007943
    ICD-10-CM-1
    N64.52
    Skin structure of breast
    Descrição

    Haut

    Tipo de dados

    integer

    Alias
    Code-1
    Skin structure of breast
    UMLS CUI-1
    C0149538
    SNOMED CT-1
    82038008
    Intradermal Node
    Descrição

    intradermale Knoten

    Tipo de dados

    boolean

    Alias
    Code-1
    Intradermal
    UMLS CUI-1
    C0150647
    Code-2
    Node
    UMLS CUI-2
    C0746922
    Inflammatory Breast Carcinoma
    Descrição

    inflammatorisch

    Tipo de dados

    boolean

    Alias
    Code-1
    Inflammatory Breast Carcinoma
    UMLS CUI-1
    C0278601
    SNOMED CT-1
    254840009
    MedDRA-1
    10021980
    Consistency of breast
    Descrição

    Brustkonsistenz

    Tipo de dados

    integer

    Alias
    Code-1
    Consistency of breast (observable entity)
    UMLS CUI-1
    C1286084
    SNOMED CT-1
    364373009
    Site of finding
    Descrição

    Seite Befund

    Tipo de dados

    integer

    Alias
    Code-Info
    for_compare
    Code-1
    Side
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Finding
    UMLS CUI-2
    C1285578
    SNOMED CT-2
    363787002
    Palpatory diagnosis
    Descrição

    auffälliger Tastbefund

    Tipo de dados

    integer

    Alias
    Code-Info
    merged_coding
    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
    Count of entities
    Descrição

    Anzahl

    Tipo de dados

    string

    Alias
    Code-Info
    merged_coding
    Code-1
    Count of entities (property) (qualifier value)
    UMLS CUI-1
    C0449788
    SNOMED CT-1
    410681005
    Code-2
    Palpatory diagnosis (qualifier value)
    UMLS CUI-2
    C1562881
    SNOMED CT-2
    416400009
    Code-3
    Breast
    UMLS CUI-3
    C0006141
    SNOMED CT-3
    76752008
    LOINC-3
    MTHU011382
    Clockface position
    Descrição

    Uhr

    Tipo de dados

    integer

    Alias
    Code-Info
    merged_coding
    Code-1
    Clockface position (qualifier value)
    UMLS CUI-1
    C0442310
    SNOMED CT-1
    272485000
    Code-3
    Clinical
    UMLS CUI-3
    C0205210
    SNOMED CT-3
    58147004
    breast lump size
    Descrição

    Größe

    Tipo de dados

    integer

    Alias
    Code-Info
    merged_coding
    Code-1
    On examination - breast lump size (finding
    UMLS CUI-1
    C0437115
    SNOMED CT-1
    163474006
    Code-3
    Clinical
    UMLS CUI-3
    C0205210
    SNOMED CT-3
    58147004
    Suspected
    Descrição

    Suspekt

    Tipo de dados

    boolean

    Alias
    Code-Info
    merged_coding
    Code-1
    Suspected
    UMLS CUI-1
    C0750491
    SNOMED CT-1
    415684004
    Code-3
    Clinical
    UMLS CUI-3
    C0205210
    SNOMED CT-3
    58147004
    Site of lymph node
    Descrição

    Seite Lymphknoten

    Tipo de dados

    integer

    Alias
    Code-Info
    for_compare
    Code-1
    Site of lymph node (observable entity)
    UMLS CUI-1
    C1302572
    SNOMED CT-1
    399635006
    lymph nodes
    Descrição

    Lymphknoten

    Tipo de dados

    integer

    Alias
    Code-1
    lymph nodes
    UMLS CUI-1
    C0024204
    SNOMED CT-1
    59441001
    LOINC-1
    MTHU015050
    Code-2
    Clinical
    UMLS CUI-2
    C0205210
    SNOMED CT-2
    58147004
    drawing
    Descrição

    "Zeichnung klin."

    Tipo de dados

    string

    Alias
    Code-1
    Drawings (art)
    UMLS CUI-1
    C0013113
    Ultrasonography
    Descrição

    Ultrasonography

    drawing sonography
    Descrição

    "Zeichnung Sono"

    Tipo de dados

    string

    Alias
    Code-1
    Drawings (art)
    UMLS CUI-1
    C0013113
    Code-2
    Ultrasonography, Mammary
    UMLS CUI-2
    C0080264
    SNOMED CT-2
    47079000
    HL7 V3-2
    12
    Site of sonography
    Descrição

    Seite Sono

    Tipo de dados

    integer

    Alias
    Code-Info
    for_compare
    Code-1
    Side
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Ultrasonography, Mammary
    UMLS CUI-2
    C0080264
    SNOMED CT-2
    47079000
    Numbers
    Descrição

    Nr.

    Tipo de dados

    integer

    Alias
    Code-1
    Numbers
    UMLS CUI-1
    C0237753
    SNOMED CT-1
    260299005
    LOINC-1
    MTHU024869
    Clockface position
    Descrição

    Uhr

    Tipo de dados

    integer

    Alias
    Code-1
    Clockface position (qualifier value)
    UMLS CUI-1
    C0442310
    SNOMED CT-1
    272485000
    Code-2
    Ultrasonography, Mammary
    UMLS CUI-2
    C0080264
    SNOMED CT-2
    47079000
    HL7 V3-2
    12
    size
    Descrição

    Metrik

    Tipo de dados

    string

    Alias
    Code-1
    Lesion size (observable entity)
    UMLS CUI-1
    C0449453
    SNOMED CT-1
    246116008
    Code-2
    Ultrasonography, Mammary
    UMLS CUI-2
    C0080264
    SNOMED CT-2
    47079000
    BI-RADS ultrasound
    Descrição

    Dignität (BIRADS I-V)

    Tipo de dados

    string

    Alias
    Code-1
    set of BI-RADS ultrasound terms
    UMLS CUI-1
    CL426924
    lymph nodes
    Descrição

    Lymphknoten

    Tipo de dados

    integer

    Alias
    Code-1
    lymph nodes
    UMLS CUI-1
    C0024204
    SNOMED CT-1
    59441001
    LOINC-1
    MTHU015050
    Code-2
    Ultrasonography, Mammary
    UMLS CUI-2
    C0080264
    SNOMED CT-2
    47079000
    HL7 V3-2
    12
    Lesion number
    Descrição

    Target Nr.

    Tipo de dados

    integer

    Alias
    Code-1
    Lesion Number
    UMLS CUI-1
    C0449791
    SNOMED CT-1
    246206008
    Side Lesion
    Descrição

    Seite Läsion

    Tipo de dados

    integer

    Alias
    Code-Info
    for_compare
    Code-1
    Side
    UMLS CUI-1
    C0441987
    SNOMED CT-1
    182353008
    LOINC-1
    MTHU014973
    Code-2
    Lesion
    UMLS CUI-2
    C0221198
    SNOMED CT-2
    49755003
    Form
    Descrição

    Form

    Tipo de dados

    integer

    Alias
    Code-1
    Form (attribute)
    UMLS CUI-1
    C0348078
    SNOMED CT-1
    246176004
    Code-2
    Lesion
    UMLS CUI-2
    C0221198
    SNOMED CT-2
    49755003
    Axis
    Descrição

    Achse

    Tipo de dados

    integer

    Alias
    Code-1
    Axis
    UMLS CUI-1
    C1522496
    Margin
    Descrição

    Begrenzung

    Tipo de dados

    integer

    Alias
    Code-Info
    merged_coding
    Code-1
    Margin
    UMLS CUI-1
    C0205284
    SNOMED CT-1
    112233002
    Code-2
    Ultrasonography, Mammary
    UMLS CUI-2
    C0080264
    SNOMED CT-2
    47079000
    HL7 V3-2
    12
    echogenicity
    Descrição

    Echogenität

    Tipo de dados

    integer

    Alias
    Code-1
    Ultrasonographic echogenicity (observable entity)
    UMLS CUI-1
    C1719852
    SNOMED CT-1
    421222001
    echotexture
    Descrição

    Echostruktur

    Tipo de dados

    integer

    Alias
    Code-1
    echotexture
    UMLS CUI-1
    CL427892
    posterior acoustic enhancement
    Descrição

    zentrale Schalverstärkung

    Tipo de dados

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    posterior acoustic enhancement
    UMLS CUI-1
    CL427825
    posterior acoustic shadowing
    Descrição

    Zentralschatten

    Tipo de dados

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    posterior acoustic shadowing
    UMLS CUI-1
    CL427967
    Acoustic shadowing unilateral
    Descrição

    unilat. Schallauslöschung

    Tipo de dados

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Acoustic shadowing of mass (observable entity)
    UMLS CUI-1
    C1719833
    SNOMED CT-1
    420527001
    Code-2
    Unilateral
    UMLS CUI-2
    C0205092
    SNOMED CT-2
    66459002
    Acoustic shadowing bilateral
    Descrição

    bilaterale Schallauslöschung

    Tipo de dados

    boolean

    Alias
    Code-Info
    changed_datatype
    Code-1
    Acoustic shadowing of mass (observable entity)
    UMLS CUI-1
    C1719833
    SNOMED CT-1
    420527001
    Code-2
    Bilateral
    UMLS CUI-2
    C0238767
    SNOMED CT-2
    51440002
    not_coded
    Descrição

    Destruktionsphänomen

    Tipo de dados

    integer

    not_coded
    Descrição

    Komprimierbarkeit

    Tipo de dados

    integer

    Vessels
    Descrição

    Gefäße

    Tipo de dados

    integer

    Alias
    Code-1
    Blood Vessels
    UMLS CUI-1
    C0005847
    SNOMED CT-1
    59820001
    LOINC-1
    MTHU001441
    Biopsy
    Descrição

    Biopsie/Punktion durchgeführt

    Tipo de dados

    boolean

    Alias
    Code-1
    Biopsy
    UMLS CUI-1
    C0005558
    SNOMED CT-1
    86273004
    MedDRA-1
    10004720
    LOINC-1
    MTHU028106
    Ultrasound-guided Biopsy
    Descrição

    Ultraschallgestütze Stanzbiopsie

    Tipo de dados

    boolean

    Alias
    Code-1
    Ultrasound-guided Biopsy
    UMLS CUI-1
    C0456900
    SNOMED CT-1
    277667006
    Puncture of cyst
    Descrição

    Cystenpunktion

    Tipo de dados

    boolean

    Alias
    Code-1
    Puncture and aspiration of cyst (procedure)
    UMLS CUI-1
    C2733030
    SNOMED CT-1
    443803004
    Lesion number
    Descrição

    Herdbefund Nr.

    Tipo de dados

    integer

    Alias
    Code-1
    Lesion Number
    UMLS CUI-1
    C0449791
    SNOMED CT-1
    246206008
    count of Punches
    Descrição

    Anzahl der Stanzen

    Tipo de dados

    integer

    Alias
    Code-1
    Punch biopsy (procedure)
    UMLS CUI-1
    C0184924
    SNOMED CT-1
    68660007
    Code-2
    Count of entities (property) (qualifier value)
    UMLS CUI-2
    C0449788
    SNOMED CT-2
    410681005
    not_coded
    Descrição

    Herd nach Stanze verändert

    Tipo de dados

    integer

    Photo documentation
    Descrição

    Fotodokumentation

    Tipo de dados

    boolean

    Alias
    Code-1
    Photo documentation
    UMLS CUI-1
    C0946283
    LOINC-1
    MTHU013840
    Date
    Descrição

    Datum

    Tipo de dados

    date

    Alias
    Code-1
    Date in time
    UMLS CUI-1
    C0011008
    SNOMED CT-1
    410671006
    LOINC-1
    MTHU021546
    Code-2
    Signature of responsible attending physician on file
    UMLS CUI-2
    C0807938
    signature
    Descrição

    Unterschrift

    Tipo de dados

    string

    Alias
    Code-1
    Signature of responsible attending physician on file
    UMLS CUI-1
    C0807938
    procedures
    Descrição

    procedures

    additional medical imaging
    Descrição

    Weiterführende Bildgebung

    Tipo de dados

    boolean

    Alias
    Code-1
    Additional
    UMLS CUI-1
    C1524062
    LOINC-1
    MTHU013802
    Code-2
    Imaging, Medical
    UMLS CUI-2
    C0025086
    Mammography
    Descrição

    Mammografie

    Tipo de dados

    boolean

    Alias
    UMLS CUI-1
    C0024671
    SNOMED CT-1
    71651007
    MedDRA-1
    10026735
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    date Mammography
    Descrição

    Mammografie

    Tipo de dados

    date

    Alias
    UMLS CUI-1
    C0024671
    SNOMED CT-1
    71651007
    MedDRA-1
    10026735
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    Ultrasonography
    Descrição

    Sonografie

    Tipo de dados

    boolean

    Alias
    Code-1
    Ultrasonography, Mammary
    UMLS CUI-1
    C0080264
    SNOMED CT-1
    47079000
    HL7 V3-1
    12
    Code-2
    Plan
    UMLS CUI-2
    C1301732
    SNOMED CT-2
    397943006
    date Ultrasonography
    Descrição

    Sonografie

    Tipo de dados

    date

    Alias
    Code-1
    Ultrasonography, Mammary
    UMLS CUI-1
    C0080264
    SNOMED CT-1
    47079000
    HL7 V3-1
    12
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    other medical imaging
    Descrição

    Sonstige

    Tipo de dados

    boolean

    Alias
    Code-1
    Other
    UMLS CUI-1
    C0205394
    SNOMED CT-1
    74964007
    Code-2
    Imaging, Medical
    UMLS CUI-2
    C0025086
    Code-3
    Plan
    UMLS CUI-3
    C1301732
    SNOMED CT-3
    397943006
    date other medical imaging
    Descrição

    Sonstige

    Tipo de dados

    date

    Alias
    Code-1
    Other
    UMLS CUI-1
    C0205394
    SNOMED CT-1
    74964007
    Code-2
    Imaging, Medical
    UMLS CUI-2
    C0025086
    Code-3
    Date in time
    UMLS CUI-3
    C0011008
    SNOMED CT-3
    410671006
    LOINC-3
    MTHU021546
    cancer conference
    Descrição

    Anmeldung TuKo

    Tipo de dados

    boolean

    Alias
    Code-1
    Registration
    UMLS CUI-1
    C1514821
    Code-2
    Cancer conference
    UMLS CUI-2
    C0805438
    Date cancer conference
    Descrição

    TuKo

    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
    Aftercare
    Descrição

    reguläre weitere Vorsorge

    Tipo de dados

    boolean

    Alias
    UMLS CUI-1
    C0001758
    SNOMED CT-1
    413467001
    Follow-Up
    Descrição

    Wiedervorstellung

    Tipo de dados

    boolean

    Alias
    Code-1
    Follow-up visit (procedure)
    UMLS CUI-1
    C0589121
    SNOMED CT-1
    185389009
    Date Follow-Up
    Descrição

    Wiedervorstellung

    Tipo de dados

    date

    Alias
    Code-1
    Follow-up visit (procedure)
    UMLS CUI-1
    C0589121
    SNOMED CT-1
    185389009
    Code-2
    Date in time
    UMLS CUI-2
    C0011008
    SNOMED CT-2
    410671006
    LOINC-2
    MTHU021546
    free text
    Descrição

    Freitext

    Tipo de dados

    string

    Alias
    Code-1
    Free Text Format
    UMLS CUI-1
    C2348713
    Date
    Descrição

    Datum

    Tipo de dados

    date

    Alias
    Code-1
    Date in time
    UMLS CUI-1
    C0011008
    SNOMED CT-1
    410671006
    LOINC-1
    MTHU021546
    Code-2
    Signature of responsible attending physician on file
    UMLS CUI-2
    C0807938
    signature
    Descrição

    Unterschrift

    Tipo de dados

    string

    Alias
    Code-1
    Signature of responsible attending physician on file
    UMLS CUI-1
    C0807938

    Similar models

    EHR breast cancer

    1. StudyEvent: HIS
      1. EHR breast cancer
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de dados
    Alias
    Item Group
    Patientenaufkleber groß
    C1320722 (UMLS CUI-1)
    Admission date
    Item
    Admission date
    date
    Date of admission (Code-1)
    399423000 (SNOMED CT-1)
    MTHU029790 (LOINC-1)
    C1302393 (UMLS CUI-1)
    Patient ID
    Item
    Patient Identification Number
    integer
    Patient Identification Number or Provider Account Number:Identifier:Point in time:^Patient:Nominal (Code-1)
    52463-7 (LOINC-1)
    C2706086 (UMLS CUI-1)
    Gender
    Item
    Patient sex
    text
    184100006 (SNOMED CT-1)
    C0150831 (UMLS CUI-1)
    Last name
    Item
    Patient surname
    text
    184096005 (SNOMED CT-1)
    C1301584 (UMLS CUI-1)
    First name
    Item
    Patient forename
    text
    184095009 (SNOMED CT-1)
    C1443235 (UMLS CUI-1)
    Date of Birth
    Item
    Patient date of birth
    date
    184099003 (SNOMED CT-1)
    C0421451 (UMLS CUI-1)
    Admission time
    Item
    Admission hour
    time
    Date of admission (Code-1)
    399423000 (SNOMED CT-1)
    MTHU029790 (LOINC-1)
    Hour (Code-2)
    258702006 (SNOMED CT-2)
    HR (HL7 V3-2)
    C2215405 (UMLS CUI-1)
    Referring physician
    Item
    Physician admission
    text
    Admission (Code-1)
    Physicians (Code-2)
    112247003 (SNOMED CT-2)
    MTHU010489 (LOINC-2)
    PHYS (HL7 V3-2)
    C1709880 (UMLS CUI-1)
    Assessment date
    Item
    date
    C2985720 (UMLS CUI-1)
    Item Group
    Anamnesebogen
    C0262926 (UMLS CUI-1)
    Anamnese erhoben durch
    Item
    Responsible Person for medical case
    string
    Responsible Person (Code-1)
    C1273518 (UMLS CUI-1)
    394851003 (SNOMED CT-1)
    Medical History (Code-2)
    C0262926 (UMLS CUI-2)
    417662000 (SNOMED CT-2)
    MTHU027722 (LOINC-2)
    Zuweisender Arzt
    Item
    Referring Physician
    string
    Referring Physician (Code-1)
    C1709880 (UMLS CUI-1)
    FFA
    Item
    Gynecologist
    string
    Gynecologist (Code-1)
    C0237419 (UMLS CUI-1)
    83685006 (SNOMED CT-1)
    207VG0400X (HL7 V3-1)
    Überweisungsgrund
    Item
    Reason for Referring
    string
    Referring (Code-1)
    C0205543 (UMLS CUI-1)
    Indication of (contextual qualifier) (Code-2)
    C0392360 (UMLS CUI-2)
    410666004 (SNOMED CT-2)
    MTHU008862 (LOINC-2)
    Item
    Reason for patient visit
    integer
    Reason for patient visit (Code-1)
    C1704447 (UMLS CUI-1)
    103324002 (SNOMED CT-1)
    MTHU013910 (LOINC-1)
    Code List
    Reason for patient visit
    CL Item
    Secondary Prevention  (Vorsorge)
    Secondary Prevention (Code-1)
    C0679699 (UMLS CUI-1)
    315234002 (SNOMED CT-1)
    10067625 (MedDRA-1)
    CL Item
    Incidental Finding (Zufallsbefund)
    Incidental Finding (Code-1)
    C0743997 (UMLS CUI-1)
    CL Item
    Aftercare (Nachsorge)
    Aftercare (Code-1)
    C0001758 (UMLS CUI-1)
    413467001 (SNOMED CT-1)
    CL Item
    Symptoms (Symptomatik)
    Symptoms (Code-1)
    C1457887 (UMLS CUI-1)
    MTHU021540 (LOINC-1)
    780-789,99 (ICD-9-CM-1)
    CL Item
    Self-Examination  (Selbstuntersuchung)
    C0080142 (UMLS CUI-1)
    409978001 (SNOMED CT-1)
    CL Item
    Screening procedure (Screening)
    C0220908 (UMLS CUI-1)
    275926002 (SNOMED CT-1)
    Anamnese
    Item
    Medical History
    string
    Medical History (Code-1)
    C0262926 (UMLS CUI-1)
    417662000 (SNOMED CT-1)
    MTHU027722 (LOINC-1)
    Item
    Menopause Status
    integer
    Menopause finding (finding) (Code-1)
    C0455962 (UMLS CUI-1)
    276477006 (SNOMED CT-1)
    Code List
    Menopause Status
    CL Item
    Premenopause (Prämenopause)
    Premenopausal state (finding) (Code-1)
    C0232969 (UMLS CUI-1)
    22636003 (SNOMED CT-1)
    CL Item
    Postmenopause (Postmenopause)
    Postmenopausal (Code-1)
    C0232970 (UMLS CUI-1)
    76498008 (SNOMED CT-1)
    CL Item
    Perimenopause (peripausal)
    C0993589 (UMLS CUI-1)
    198435007 (SNOMED CT-1)
    10062974 (MedDRA-1)
    CL Item
    unknown Menopause finding (unbekannt)
    Unknown (Code-1)
    C0439673 (UMLS CUI-1)
    261665006 (SNOMED CT-1)
    Schwangerschaften
    Item
    quantity of pregnancy
    integer
    Finding of quantity of pregnancy (finding) (Code-1)
    C0566634 (UMLS CUI-1)
    289204008 (SNOMED CT-1)
    Stillzeit (Monate)
    Item
    Months of breast feeding
    integer
    Months of breast feeding (Code-1)
    C3172259 (UMLS CUI-1)
    Akuelle Medikamente
    Item
    Drugs
    integer
    Pharmaceutical Preparations (Code-1)
    C0013227 (UMLS CUI-1)
    410942007 (SNOMED CT-1)
    Pille
    Item
    Contraceptives
    boolean
    Contraceptives, Oral (Code-1)
    C0009905 (UMLS CUI-1)
    423938009 (SNOMED CT-1)
    HRT
    Item
    Hormone replacement therapy
    boolean
    Hormone replacement therapy (Code-1)
    C0282402 (UMLS CUI-1)
    266717002 (SNOMED CT-1)
    10020388 (MedDRA-1)
    ASS
    Item
    Aspirin
    boolean
    Aspirin (Code-1)
    C0004057 (UMLS CUI-1)
    387458008 (SNOMED CT-1)
    Marcumar
    Item
    Phenprocoumon
    boolean
    Phenprocoumon (Code-1)
    C0031444 (UMLS CUI-1)
    59488002 (SNOMED CT-1)
    MTHU016364 (LOINC-1)
    Allergien
    Item
    Allergic Reaction
    string
    Allergic Reaction (Code-1)
    C1527304 (UMLS CUI-1)
    106190000 (SNOMED CT-1)
    10020751 (MedDRA-1)
    T78.40 (ICD-10-CM-1)
    E11248 (CTCAE-1)
    ALG (HL7 V3-1)
    Nikotin
    Item
    Tobacco smoking
    boolean
    Tobacco smoking behavior (Code-1)
    C0453996 (UMLS CUI-1)
    365981007 (SNOMED CT-1)
    Zig./die
    Item
    How many cigarettes per day do, or did, you smoke
    integer
    How many cigarettes per day do, or did, you smoke (Code-1)
    C3169451 (UMLS CUI-1)
    MTHU037005 (LOINC-1)
    Alkohol
    Item
    Alcohol consumption
    boolean
    Alcohol consumption (Code-1)
    C0001948 (UMLS CUI-1)
    160573003 (SNOMED CT-1)
    10048921 (MedDRA-1)
    Alkohol
    Item
    Details of drinking behavior
    string
    Details of drinking behavior (Code-1)
    C1285666 (UMLS CUI-1)
    363905002 (SNOMED CT-1)
    Family history
    Item
    text
    C0241889 (UMLS CUI-1)
    Item Group
    Pre-existing Condition
    Vorerkrankungen/Voroperationen
    Item
    Pre-existing Condition
    boolean
    Pre-existing Condition (Code-1)
    C0521987 (UMLS CUI-1)
    102478008 (SNOMED CT-1)
    Thrombose
    Item
    Thrombosis
    boolean
    Thrombosis (Code-1)
    C0040053 (UMLS CUI-1)
    439127006 (SNOMED CT-1)
    10043607 (MedDRA-1)
    Erkrankungen/Operationen
    Item
    Pre-existing Condition
    string
    Pre-existing Condition (Code-1)
    C0521987 (UMLS CUI-1)
    102478008 (SNOMED CT-1)
    Datum/Jahr
    Item
    Date pre-existing condition
    date
    Date in time (Code-1)
    C0011008 (UMLS CUI-1)
    410671006 (SNOMED CT-1)
    MTHU021546 (LOINC-1)
    Pre-existing Condition (Code-2)
    C0521987 (UMLS CUI-2)
    102478008 (SNOMED CT-2)
    Therapie
    Item
    therapy
    string
    Therapeutic procedure (Code-1)
    C0087111 (UMLS CUI-1)
    277132007 (SNOMED CT-1)
    10053757 (MedDRA-1)
    MTHU008880 (LOINC-1)
    Pre-existing Condition (Code-2)
    C0521987 (UMLS CUI-2)
    102478008 (SNOMED CT-2)
    Item Group
    External Result
    Mammografie
    Item
    Mammography
    boolean
    Mammography (Code-1)
    C0024671 (UMLS CUI-1)
    71651007 (SNOMED CT-1)
    10026735 (MedDRA-1)
    Mammografie
    Item
    Date Mammography
    date
    Mammography (Code-1)
    C0024671 (UMLS CUI-1)
    71651007 (SNOMED CT-1)
    10026735 (MedDRA-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    Item
    Site of finding
    integer
    for_compare (Code-Info)
    Side (Code-1)
    C0441987 (UMLS CUI-1)
    182353008 (SNOMED CT-1)
    MTHU014973 (LOINC-1)
    Imaging, Medical (Code-2)
    C0025086 (UMLS CUI-2)
    Code List
    Site of finding
    CL Item
    right (rechts)
    for_compare (Code-Info)
    Right (Code-1)
    C0205090 (UMLS CUI-1)
    24028007 (SNOMED CT-1)
    CL Item
    left (links)
    for_compare (Code-Info)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    BIRADS
    Item
    BI-RADS mammo
    integer
    merged_coding (Code-Info)
    set of BI-RADS mammo terms (Code-1)
    CL426926 (UMLS CUI-1)
    Sonografie
    Item
    Sonography
    boolean
    Ultrasonography, Mammary (Code-1)
    C0080264 (UMLS CUI-1)
    47079000 (SNOMED CT-1)
    Sonografie
    Item
    Date Sonography
    date
    Ultrasonography, Mammary (Code-1)
    C0080264 (UMLS CUI-1)
    47079000 (SNOMED CT-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    BIRADSanalog
    Item
    BI-RADS ultrasound
    integer
    merged_coding (Code-Info)
    set of BI-RADS ultrasound terms (Code-1)
    CL426924 (UMLS CUI-1)
    MR-MG
    Item
    Magnetic Resonance Imaging of breast
    boolean
    Magnetic resonance imaging of breast (procedure) (Code-1)
    C0344104 (UMLS CUI-1)
    241615005 (SNOMED CT-1)
    MR-MG
    Item
    date Magnetic Resonance Imaging of breast
    date
    Magnetic resonance imaging of breast (procedure) (Code-1)
    C0344104 (UMLS CUI-1)
    241615005 (SNOMED CT-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    MR-BIRADS
    Item
    BI-RADS MRI
    integer
    set of BI-RADS MRI terms (Code-1)
    CL426925 (UMLS CUI-1)
    Histologie
    Item
    Histopathology
    boolean
    Histopathology (Code-1)
    C0677043 (UMLS CUI-1)
    394597005 (SNOMED CT-1)
    Sonstiges
    Item
    other result
    boolean
    Other (Code-1)
    C0205394 (UMLS CUI-1)
    74964007 (SNOMED CT-1)
    Result (Code-2)
    C1274040 (UMLS CUI-2)
    394617004 (SNOMED CT-2)
    Item Group
    Physical Examination
    Item
    Breast size
    integer
    Breast size (observable entity) (Code-1)
    C0425782 (UMLS CUI-1)
    248808008 (SNOMED CT-1)
    Code List
    Breast size
    CL Item
    not_coded (A)
    CL Item
    not_coded (B)
    CL Item
    not_coded (C)
    CL Item
    not_coded (D)
    CL Item
    not_coded (> D)
    Item
    Ptosis of breast
    integer
    Ptosis of breast (Code-1)
    C2233848 (UMLS CUI-1)
    N64.81 (ICD-10-CM-1)
    611.81 (ICD-9-CM-1)
    Code List
    Ptosis of breast
    CL Item
    None (keine)
    None (Code-1)
    C0549184 (UMLS CUI-1)
    260413007 (SNOMED CT-1)
    CL Item
    medium (mittel)
    Medium (Code-1)
    C0439536 (UMLS CUI-1)
    255508009 (SNOMED CT-1)
    CL Item
    marked (ausgeprägt)
    Massive (qualifier value) (Code-1)
    C0522501 (UMLS CUI-1)
    46998006 (SNOMED CT-1)
    Item
    Symmetry
    integer
    Symmetry of breasts (observable entity) (Code-1)
    C0425778 (UMLS CUI-1)
    Code List
    Symmetry
    CL Item
    symmetry of breasts (ja)
    Finding of symmetry of breasts (finding) (Code-1)
    C1287869 (UMLS CUI-1)
    366348007 (SNOMED CT-1)
    CL Item
    breast asymmetry (nein)
    On examination - breast asymmetry (finding) (Code-1)
    C0437091 (UMLS CUI-1)
    163438002 (SNOMED CT-1)
    CL Item
    no: li>re (nein: li>re)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    Greater (Code-2)
    C1704243 (UMLS CUI-2)
    263768009 (SNOMED CT-2)
    Right (Code-3)
    C0205090 (UMLS CUI-3)
    24028007 (SNOMED CT-3)
    CL Item
    no: li<re (nein: li<re)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    Lesser (Code-2)
    C0547044 (UMLS CUI-2)
    263796003 (SNOMED CT-2)
    Right (Code-3)
    C0205090 (UMLS CUI-3)
    24028007 (SNOMED CT-3)
    Item
    nipple discharge
    integer
    nipple discharge (Code-1)
    C0149741 (UMLS CUI-1)
    54302000 (SNOMED CT-1)
    10006223 (MedDRA-1)
    MTHU007943 (LOINC-1)
    N64.52 (ICD-10-CM-1)
    Code List
    nipple discharge
    CL Item
    No nipple discharge  (nein)
    No nipple discharge (finding) (Code-1)
    C0425813 (UMLS CUI-1)
    162165008 (SNOMED CT-1)
    CL Item
    Nipple discharge present  (ja)
    Nipple discharge present (disorder) (Code-1)
    C0425812 (UMLS CUI-1)
    162166009 (SNOMED CT-1)
    CL Item
    Serosanguineous nipple discharge  (ja: blutig)
    Serosanguineous nipple discharge (disorder (Code-1)
    C0567521 (UMLS CUI-1)
    290110007 (SNOMED CT-1)
    CL Item
    Serous nipple discharge (ja: serös)
    Serous nipple discharge (disorder) (Code-1)
    C0567520 (UMLS CUI-1)
    290109002 (SNOMED CT-1)
    CL Item
    Milky nipple discharge  (ja: milchig)
    Milky nipple discharge (disorder) (Code-1)
    C0567523 (UMLS CUI-1)
    290112004 (SNOMED CT-1)
    Item
    Skin structure of breast
    integer
    Skin structure of breast (Code-1)
    C0149538 (UMLS CUI-1)
    82038008 (SNOMED CT-1)
    Code List
    Skin structure of breast
    CL Item
    Normal (unauffällig)
    Normal (Code-1)
    C0205307 (UMLS CUI-1)
    17621005 (SNOMED CT-1)
    CL Item
    skin retraction (Einziehung)
    skin retraction (Code-1)
    CL427939 (UMLS CUI-1)
    CL Item
    plateau (Plateau)
    plateau (Code-1)
    CL427821 (UMLS CUI-1)
    CL Item
    breast edema (Ödem)
    BREAST EDEMA (Code-1)
    C0235649 (UMLS CUI-1)
    290077003 (SNOMED CT-1)
    10006294 (MedDRA-1)
    CL Item
    Ulceration of breast  (Ulzeration)
    Ulceration of breast (finding) (Code-1)
    C0425793 (UMLS CUI-1)
    248818003 (SNOMED CT-1)
    intradermale Knoten
    Item
    Intradermal Node
    boolean
    Intradermal (Code-1)
    C0150647 (UMLS CUI-1)
    Node (Code-2)
    C0746922 (UMLS CUI-2)
    inflammatorisch
    Item
    Inflammatory Breast Carcinoma
    boolean
    Inflammatory Breast Carcinoma (Code-1)
    C0278601 (UMLS CUI-1)
    254840009 (SNOMED CT-1)
    10021980 (MedDRA-1)
    Item
    Consistency of breast
    integer
    Consistency of breast (observable entity) (Code-1)
    C1286084 (UMLS CUI-1)
    364373009 (SNOMED CT-1)
    Code List
    Consistency of breast
    CL Item
    Normal breast consistency (weich, gut beurteilbar)
    Normal breast consistency (finding) (Code-1)
    C0567480 (UMLS CUI-1)
    290063001 (SNOMED CT-1)
    CL Item
    breast lump consistency (knotig, schwer beurteilbar)
    On examination - breast lump consistency (finding) (Code-1)
    C0437122 (UMLS CUI-1)
    163482006 (SNOMED CT-1)
    Item
    Site of finding
    integer
    for_compare (Code-Info)
    Side (Code-1)
    C0441987 (UMLS CUI-1)
    182353008 (SNOMED CT-1)
    MTHU014973 (LOINC-1)
    Finding (Code-2)
    C1285578 (UMLS CUI-2)
    363787002 (SNOMED CT-2)
    Code List
    Site of finding
    CL Item
    right (rechts)
    for_compare (Code-Info)
    Right (Code-1)
    C0205090 (UMLS CUI-1)
    24028007 (SNOMED CT-1)
    CL Item
    left (links)
    for_compare (Code-Info)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    Item
    Palpatory diagnosis
    integer
    merged_coding (Code-Info)
    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)
    Code List
    Palpatory diagnosis
    CL Item
    No (nein (nonpalpabel))
    No (Code-1)
    C1298908 (UMLS CUI-1)
    373067005 (SNOMED CT-1)
    CL Item
    Single  (solitär)
    Single (Code-1)
    C0205171 (UMLS CUI-1)
    50607009 (SNOMED CT-1)
    CL Item
    Multiple (multiple)
    Multiple (Code-1)
    C0439064 (UMLS CUI-1)
    255204007 (SNOMED CT-1)
    Anzahl
    Item
    Count of entities
    string
    merged_coding (Code-Info)
    Count of entities (property) (qualifier value) (Code-1)
    C0449788 (UMLS CUI-1)
    410681005 (SNOMED CT-1)
    Palpatory diagnosis (qualifier value) (Code-2)
    C1562881 (UMLS CUI-2)
    416400009 (SNOMED CT-2)
    Breast (Code-3)
    C0006141 (UMLS CUI-3)
    76752008 (SNOMED CT-3)
    MTHU011382 (LOINC-3)
    Uhr
    Item
    Clockface position
    integer
    merged_coding (Code-Info)
    Clockface position (qualifier value) (Code-1)
    C0442310 (UMLS CUI-1)
    272485000 (SNOMED CT-1)
    Clinical (Code-3)
    C0205210 (UMLS CUI-3)
    58147004 (SNOMED CT-3)
    Größe
    Item
    breast lump size
    integer
    merged_coding (Code-Info)
    On examination - breast lump size (finding (Code-1)
    C0437115 (UMLS CUI-1)
    163474006 (SNOMED CT-1)
    Clinical (Code-3)
    C0205210 (UMLS CUI-3)
    58147004 (SNOMED CT-3)
    Suspekt
    Item
    Suspected
    boolean
    merged_coding (Code-Info)
    Suspected (Code-1)
    C0750491 (UMLS CUI-1)
    415684004 (SNOMED CT-1)
    Clinical (Code-3)
    C0205210 (UMLS CUI-3)
    58147004 (SNOMED CT-3)
    Item
    Site of lymph node
    integer
    for_compare (Code-Info)
    Site of lymph node (observable entity) (Code-1)
    C1302572 (UMLS CUI-1)
    399635006 (SNOMED CT-1)
    Code List
    Site of lymph node
    CL Item
    right (rechts)
    for_compare (Code-Info)
    Right (Code-1)
    C0205090 (UMLS CUI-1)
    24028007 (SNOMED CT-1)
    CL Item
    left (links)
    for_compare (Code-Info)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    Item
    lymph nodes
    integer
    lymph nodes (Code-1)
    C0024204 (UMLS CUI-1)
    59441001 (SNOMED CT-1)
    MTHU015050 (LOINC-1)
    Clinical (Code-2)
    C0205210 (UMLS CUI-2)
    58147004 (SNOMED CT-2)
    Code List
    lymph nodes
    CL Item
    Negation  (nicht tastbar)
    Negation (Code-1)
    C1518423 (UMLS CUI-1)
    Palpable (Code-2)
    C0522499 (UMLS CUI-2)
    103357000 (SNOMED CT-2)
    CL Item
    Palpable (tastbar)
    Palpable (Code-1)
    C0522499 (UMLS CUI-1)
    103357000 (SNOMED CT-1)
    CL Item
    Suspected (suspekt)
    Suspected (Code-1)
    C0750491 (UMLS CUI-1)
    415684004 (SNOMED CT-1)
    "Zeichnung klin."
    Item
    drawing
    string
    Drawings (art) (Code-1)
    C0013113 (UMLS CUI-1)
    Item Group
    Ultrasonography
    "Zeichnung Sono"
    Item
    drawing sonography
    string
    Drawings (art) (Code-1)
    C0013113 (UMLS CUI-1)
    Ultrasonography, Mammary (Code-2)
    C0080264 (UMLS CUI-2)
    47079000 (SNOMED CT-2)
    12 (HL7 V3-2)
    Item
    Site of sonography
    integer
    for_compare (Code-Info)
    Side (Code-1)
    C0441987 (UMLS CUI-1)
    182353008 (SNOMED CT-1)
    MTHU014973 (LOINC-1)
    Ultrasonography, Mammary (Code-2)
    C0080264 (UMLS CUI-2)
    47079000 (SNOMED CT-2)
    Code List
    Site of sonography
    CL Item
    right (rechts)
    for_compare (Code-Info)
    Right (Code-1)
    C0205090 (UMLS CUI-1)
    24028007 (SNOMED CT-1)
    CL Item
    left (links)
    for_compare (Code-Info)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    Nr.
    Item
    Numbers
    integer
    Numbers (Code-1)
    C0237753 (UMLS CUI-1)
    260299005 (SNOMED CT-1)
    MTHU024869 (LOINC-1)
    Uhr
    Item
    Clockface position
    integer
    Clockface position (qualifier value) (Code-1)
    C0442310 (UMLS CUI-1)
    272485000 (SNOMED CT-1)
    Ultrasonography, Mammary (Code-2)
    C0080264 (UMLS CUI-2)
    47079000 (SNOMED CT-2)
    12 (HL7 V3-2)
    Metrik
    Item
    size
    string
    Lesion size (observable entity) (Code-1)
    C0449453 (UMLS CUI-1)
    246116008 (SNOMED CT-1)
    Ultrasonography, Mammary (Code-2)
    C0080264 (UMLS CUI-2)
    47079000 (SNOMED CT-2)
    Dignität (BIRADS I-V)
    Item
    BI-RADS ultrasound
    string
    set of BI-RADS ultrasound terms (Code-1)
    CL426924 (UMLS CUI-1)
    Item
    lymph nodes
    integer
    lymph nodes (Code-1)
    C0024204 (UMLS CUI-1)
    59441001 (SNOMED CT-1)
    MTHU015050 (LOINC-1)
    Ultrasonography, Mammary (Code-2)
    C0080264 (UMLS CUI-2)
    47079000 (SNOMED CT-2)
    12 (HL7 V3-2)
    Code List
    lymph nodes
    CL Item
    Normal (unauffällig)
    Normal (Code-1)
    C0205307 (UMLS CUI-1)
    17621005 (SNOMED CT-1)
    CL Item
    Suspected (suspekt)
    Suspected (Code-1)
    C0750491 (UMLS CUI-1)
    415684004 (SNOMED CT-1)
    CL Item
    Pathologic (pathologisch)
    Pathologic (Code-1)
    C1521733 (UMLS CUI-1)
    29458008 (SNOMED CT-1)
    Target Nr.
    Item
    Lesion number
    integer
    Lesion Number (Code-1)
    C0449791 (UMLS CUI-1)
    246206008 (SNOMED CT-1)
    Item
    Side Lesion
    integer
    for_compare (Code-Info)
    Side (Code-1)
    C0441987 (UMLS CUI-1)
    182353008 (SNOMED CT-1)
    MTHU014973 (LOINC-1)
    Lesion (Code-2)
    C0221198 (UMLS CUI-2)
    49755003 (SNOMED CT-2)
    Code List
    Side Lesion
    CL Item
    Right (rechts)
    changed_datatype (Code-Info)
    Right (Code-1)
    C0205090 (UMLS CUI-1)
    24028007 (SNOMED CT-1)
    CL Item
    Left (links)
    changed_datatype (Code-Info)
    Left (Code-1)
    C0205091 (UMLS CUI-1)
    7771000 (SNOMED CT-1)
    Item
    Form
    integer
    Form (attribute) (Code-1)
    C0348078 (UMLS CUI-1)
    246176004 (SNOMED CT-1)
    Lesion (Code-2)
    C0221198 (UMLS CUI-2)
    49755003 (SNOMED CT-2)
    Code List
    Form
    CL Item
    Round (rund)
    Round (Code-1)
    C0332490 (UMLS CUI-1)
    42700002 (SNOMED CT-1)
    CL Item
    Oval (oval)
    Oval (Code-1)
    C1709367 (UMLS CUI-1)
    CL Item
    Complex (komplex)
    Complex (Code-1)
    C0439855 (UMLS CUI-1)
    103360007 (SNOMED CT-1)
    Item
    Axis
    integer
    Axis (Code-1)
    C1522496 (UMLS CUI-1)
    Code List
    Axis
    CL Item
    Horizontal (horizontal)
    Horizontal (Code-1)
    C0205126 (UMLS CUI-1)
    24020000 (SNOMED CT-1)
    CL Item
    Vertical (vertikal)
    Vertical (Code-1)
    C0205128 (UMLS CUI-1)
    33096000 (SNOMED CT-1)
    CL Item
    Indifferent (indifferent)
    Indifferent (qualifier value (Code-1)
    C0332238 (UMLS CUI-1)
    54328002 (SNOMED CT-1)
    Item
    Margin
    integer
    merged_coding (Code-Info)
    Margin (Code-1)
    C0205284 (UMLS CUI-1)
    112233002 (SNOMED CT-1)
    Ultrasonography, Mammary (Code-2)
    C0080264 (UMLS CUI-2)
    47079000 (SNOMED CT-2)
    12 (HL7 V3-2)
    Code List
    Margin
    CL Item
    Smooth  (glatt)
    Smooth (Code-1)
    C0205357 (UMLS CUI-1)
    82280004 (SNOMED CT-1)
    CL Item
    irregular (gezackt)
    Irregular (Code-1)
    C0205271 (UMLS CUI-1)
    49608001 (SNOMED CT-1)
    CL Item
    circumscribed  (scharf)
    circumscribed margin (Code-1)
    CL381530 (UMLS CUI-1)
    CL Item
    Diffuse (unscharf)
    Diffuse (Code-1)
    C0205219 (UMLS CUI-1)
    19648000 (SNOMED CT-1)
    CL Item
    echogenic halo (echoreicher Saum)
    echogenic halo (Code-1)
    CL427901 (UMLS CUI-1)
    Item
    echogenicity
    integer
    Ultrasonographic echogenicity (observable entity) (Code-1)
    C1719852 (UMLS CUI-1)
    421222001 (SNOMED CT-1)
    Code List
    echogenicity
    CL Item
    isoechoic (echogleich)
    isoechoic (Code-1)
    CL381581 (UMLS CUI-1)
    CL Item
    hypoechoic (echoarm)
    hypoechoic (Code-1)
    CL381580 (UMLS CUI-1)
    CL Item
    hyperechoic  (echoreich)
    hyperechoic (Code-1)
    CL381582 (UMLS CUI-1)
    CL Item
    anechoic (echoleer)
    anechoic (Code-1)
    CL427829 (UMLS CUI-1)
    Item
    echotexture
    integer
    echotexture (Code-1)
    CL427892 (UMLS CUI-1)
    Code List
    echotexture
    CL Item
    homogenous (homogen)
    Homogeneity (Code-1)
    C1881065 (UMLS CUI-1)
    CL Item
    heterogenous (inhomogen)
    Heterogenous (Code-1)
    C1512426 (UMLS CUI-1)
    zentrale Schalverstärkung
    Item
    posterior acoustic enhancement
    boolean
    changed_datatype (Code-Info)
    posterior acoustic enhancement (Code-1)
    CL427825 (UMLS CUI-1)
    Zentralschatten
    Item
    posterior acoustic shadowing
    boolean
    changed_datatype (Code-Info)
    posterior acoustic shadowing (Code-1)
    CL427967 (UMLS CUI-1)
    unilat. Schallauslöschung
    Item
    Acoustic shadowing unilateral
    boolean
    changed_datatype (Code-Info)
    Acoustic shadowing of mass (observable entity) (Code-1)
    C1719833 (UMLS CUI-1)
    420527001 (SNOMED CT-1)
    Unilateral (Code-2)
    C0205092 (UMLS CUI-2)
    66459002 (SNOMED CT-2)
    bilaterale Schallauslöschung
    Item
    Acoustic shadowing bilateral
    boolean
    changed_datatype (Code-Info)
    Acoustic shadowing of mass (observable entity) (Code-1)
    C1719833 (UMLS CUI-1)
    420527001 (SNOMED CT-1)
    Bilateral (Code-2)
    C0238767 (UMLS CUI-2)
    51440002 (SNOMED CT-2)
    Item
    not_coded
    integer
    Code List
    not_coded
    CL Item
    not_coded (Umgebungsarchitektur verdrängt)
    CL Item
    not_coded (unterbrochen)
    Item
    not_coded
    integer
    Code List
    not_coded
    CL Item
    not_coded (gut)
    CL Item
    not_coded (gering)
    CL Item
    not_coded (fehlend)
    Item
    Vessels
    integer
    Blood Vessels (Code-1)
    C0005847 (UMLS CUI-1)
    59820001 (SNOMED CT-1)
    MTHU001441 (LOINC-1)
    Code List
    Vessels
    CL Item
    no vessels (keine Gefäße)
    None (Code-1)
    C0549184 (UMLS CUI-1)
    260413007 (SNOMED CT-1)
    CL Item
    within tumor (im Tumor)
    Malignant Neoplasms (Code-1)
    C0006826 (UMLS CUI-1)
    363346000 (SNOMED CT-1)
    10007050 (MedDRA-1)
    MTHU010328 (LOINC-1)
    C80 (ICD-10-CM-1)
    199 (ICD-9-CM-1)
    Within (Code-2)
    C0332285 (UMLS CUI-2)
    18720000 (SNOMED CT-2)
    CL Item
    within enviroment (in Umgebung)
    Environment (Code-1)
    C0014406 (UMLS CUI-1)
    276339004 (SNOMED CT-1)
    MTHU009317 (LOINC-1)
    Within (Code-2)
    C0332285 (UMLS CUI-2)
    18720000 (SNOMED CT-2)
    Biopsie/Punktion durchgeführt
    Item
    Biopsy
    boolean
    Biopsy (Code-1)
    C0005558 (UMLS CUI-1)
    86273004 (SNOMED CT-1)
    10004720 (MedDRA-1)
    MTHU028106 (LOINC-1)
    Ultraschallgestütze Stanzbiopsie
    Item
    Ultrasound-guided Biopsy
    boolean
    Ultrasound-guided Biopsy (Code-1)
    C0456900 (UMLS CUI-1)
    277667006 (SNOMED CT-1)
    Cystenpunktion
    Item
    Puncture of cyst
    boolean
    Puncture and aspiration of cyst (procedure) (Code-1)
    C2733030 (UMLS CUI-1)
    443803004 (SNOMED CT-1)
    Herdbefund Nr.
    Item
    Lesion number
    integer
    Lesion Number (Code-1)
    C0449791 (UMLS CUI-1)
    246206008 (SNOMED CT-1)
    Anzahl der Stanzen
    Item
    count of Punches
    integer
    Punch biopsy (procedure) (Code-1)
    C0184924 (UMLS CUI-1)
    68660007 (SNOMED CT-1)
    Count of entities (property) (qualifier value) (Code-2)
    C0449788 (UMLS CUI-2)
    410681005 (SNOMED CT-2)
    Item
    not_coded
    integer
    Code List
    not_coded
    CL Item
    not_coded (nein)
    CL Item
    not_coded (kleiner)
    CL Item
    not_coded (weg)
    Fotodokumentation
    Item
    Photo documentation
    boolean
    Photo documentation (Code-1)
    C0946283 (UMLS CUI-1)
    MTHU013840 (LOINC-1)
    Datum
    Item
    Date
    date
    Date in time (Code-1)
    C0011008 (UMLS CUI-1)
    410671006 (SNOMED CT-1)
    MTHU021546 (LOINC-1)
    Signature of responsible attending physician on file (Code-2)
    C0807938 (UMLS CUI-2)
    Unterschrift
    Item
    signature
    string
    Signature of responsible attending physician on file (Code-1)
    C0807938 (UMLS CUI-1)
    Item Group
    procedures
    Weiterführende Bildgebung
    Item
    additional medical imaging
    boolean
    Additional (Code-1)
    C1524062 (UMLS CUI-1)
    MTHU013802 (LOINC-1)
    Imaging, Medical (Code-2)
    C0025086 (UMLS CUI-2)
    Mammografie
    Item
    Mammography
    boolean
    C0024671 (UMLS CUI-1)
    71651007 (SNOMED CT-1)
    10026735 (MedDRA-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    Mammografie
    Item
    date Mammography
    date
    C0024671 (UMLS CUI-1)
    71651007 (SNOMED CT-1)
    10026735 (MedDRA-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    Sonografie
    Item
    Ultrasonography
    boolean
    Ultrasonography, Mammary (Code-1)
    C0080264 (UMLS CUI-1)
    47079000 (SNOMED CT-1)
    12 (HL7 V3-1)
    Plan (Code-2)
    C1301732 (UMLS CUI-2)
    397943006 (SNOMED CT-2)
    Sonografie
    Item
    date Ultrasonography
    date
    Ultrasonography, Mammary (Code-1)
    C0080264 (UMLS CUI-1)
    47079000 (SNOMED CT-1)
    12 (HL7 V3-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    Sonstige
    Item
    other medical imaging
    boolean
    Other (Code-1)
    C0205394 (UMLS CUI-1)
    74964007 (SNOMED CT-1)
    Imaging, Medical (Code-2)
    C0025086 (UMLS CUI-2)
    Plan (Code-3)
    C1301732 (UMLS CUI-3)
    397943006 (SNOMED CT-3)
    Sonstige
    Item
    date other medical imaging
    date
    Other (Code-1)
    C0205394 (UMLS CUI-1)
    74964007 (SNOMED CT-1)
    Imaging, Medical (Code-2)
    C0025086 (UMLS CUI-2)
    Date in time (Code-3)
    C0011008 (UMLS CUI-3)
    410671006 (SNOMED CT-3)
    MTHU021546 (LOINC-3)
    Anmeldung TuKo
    Item
    cancer conference
    boolean
    Registration (Code-1)
    C1514821 (UMLS CUI-1)
    Cancer conference (Code-2)
    C0805438 (UMLS CUI-2)
    TuKo
    Item
    Date cancer conference
    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)
    reguläre weitere Vorsorge
    Item
    Aftercare
    boolean
    C0001758 (UMLS CUI-1)
    413467001 (SNOMED CT-1)
    Wiedervorstellung
    Item
    Follow-Up
    boolean
    Follow-up visit (procedure) (Code-1)
    C0589121 (UMLS CUI-1)
    185389009 (SNOMED CT-1)
    Wiedervorstellung
    Item
    Date Follow-Up
    date
    Follow-up visit (procedure) (Code-1)
    C0589121 (UMLS CUI-1)
    185389009 (SNOMED CT-1)
    Date in time (Code-2)
    C0011008 (UMLS CUI-2)
    410671006 (SNOMED CT-2)
    MTHU021546 (LOINC-2)
    Freitext
    Item
    free text
    string
    Free Text Format (Code-1)
    C2348713 (UMLS CUI-1)
    Datum
    Item
    Date
    date
    Date in time (Code-1)
    C0011008 (UMLS CUI-1)
    410671006 (SNOMED CT-1)
    MTHU021546 (LOINC-1)
    Signature of responsible attending physician on file (Code-2)
    C0807938 (UMLS CUI-2)
    Unterschrift
    Item
    signature
    string
    Signature of responsible attending physician on file (Code-1)
    C0807938 (UMLS CUI-1)

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