Peripheral Atherosclerotic Vascular Disease EHR key data elements

Beschreibung

Sex

Datentyp

integer

Alias

UMLS CUI-1

C0079399

Beschreibung

Date of Birth

Datentyp

date

Alias

UMLS CUI-1

C0421451

Beschreibung

Race

Datentyp

integer

Alias

UMLS CUI-1

C0034510

Beschreibung

Hispanic ethnicity

Datentyp

boolean

Beschreibung

Patient ZIP code

Datentyp

text

Beschreibung

Healthcare facility

Datentyp

text

Alias

UMLS CUI-1

C0018704

Beschreibung

Insurance payer

Datentyp

integer

Beschreibung

Date and time of presentation to healthcare facility

Datentyp

datetime

Beschreibung

Type of encounter

Datentyp

integer

Alias

UMLS CUI-1

C1512346

Beschreibung

Primary reason for encounter

Datentyp

integer

Beschreibung

Admission location

Datentyp

integer

Beschreibung

Means of transport

Datentyp

integer

Alias

UMLS CUI-1

C0150390

Beschreibung

Location of encounter

Datentyp

integer

Beschreibung

Indicate if the patient has a current or previous diagnosis of hypertension as defined by any of the following: - History of hypertension diagnosed and treated with medication, diet, and/or exercise - On at least 2 occasions, documented blood pressure >140 mm Hg systolic and/or 90 mm Hg diastolic in patients without diabetes or chronic kidney disease; >130 mm Hg systolic or 80 mm Hg diastolic in patients with diabetes or chronic kidney disease - Currently on pharmacological therapy for treatment of hypertension More than 1 of the above may apply. The year of onset (first diagnosis) may be helpful.

Datentyp

text

Alias

UMLS CUI-1

C0455527

Beschreibung

History of diabetes diagnosed and/or treated by a physician. The American Diabetes Association criteria include documentation of the following - Hemoglobin A1c >6.5%; or - Fasting plasma glucose >126 mg/dL (7.0 mmol/L); or - Two-hour plasma glucose >200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test; or - In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose >200 mg/dL (11.1 mmol/L). This does not include gestational diabetes. Indicate the following: 1. Type 1 or type 2 diabetes 2. Year of onset (if known)

Datentyp

text

Alias

UMLS CUI-1

C0455488

Beschreibung

Current or previous diagnosis of dyslipidemia per the National Cholesterol Education Program criteria, defined as any 1 of the following: - Total cholesterol >200 mg/dL (5.18 mmol/L) - LDL >=130 mg/dL (3.37 mmol/L) - HDL <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.30 mmol/L) in women Treatment is also initiated if LDL is >100 mg/dL (2.59 mmol/L) in patients with known coronary artery disease or CHD equivalent, and this would qualify as hypercholesterolemia.

Datentyp

text

Alias

UMLS CUI-1

C0242339

UMLS CUI-2

C0332119

Beschreibung

History confirming cigarette smoking in the past.

Datentyp

integer

Alias

UMLS CUI-1

C1519384

Beschreibung

Specify the patient’s history of alcohol consumption. Choose from the following categories: - None - <=1 alcoholic drinks/wk - 2–7 alcoholic drinks/wk - 8–13 alcoholic drinks/wk - 14–20 alcoholic drinks/wk - >=21 alcoholic drinks/wk Specify alcohol-dependency history. Choose all that apply: Documented alcohol dependency Medical sequelae of alcohol consumption (alcoholic hepatitis, cirrhosis, alcohol neuropathy, Wernicke-Korsakoff syndrome) Treatment for alcohol dependency For patients with alcohol dependency, note treatment for dependency, cessation of use, or continued use.

Datentyp

text

Alias

UMLS CUI-1

C0552479

Beschreibung

Indicate history of current, recent, or remote abuse of any illicit drug (eg, cocaine, methamphetamine, marijuana) or controlled substance.

Datentyp

boolean

Alias

UMLS CUI-1

C2239127

Beschreibung

The term myocardial infarction should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. Under these conditions, any 1 of the following criteria meets the diagnosis for MI: 1) Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least 1 value above the 99th percentile of URL together with evidence of myocardial ischemia with at least 1 of the following: — Symptoms of ischemia — Electrocardiographic changes indicative of new ischemia (new ST-T changes or new LBBB) — Development of pathological Q waves in the ECG — Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality 2) Sudden unexpected cardiac death, involving cardiac arrest, often with symptoms suggestive of myocardial ischemia, and accompanied by presumably new ST elevation or new LBBB and/or evidence of fresh thrombus by coronary angiography a time before the appearance of cardiac biomarkers in the blood. 3) For PCI in patients with normal baseline indicative of periprocedural myocardial necrosis. By convention, increases of biomarkers >3x99th percentile URL have been designated as PCI-related MI. A subtype related to a documented stent thrombosis is recognized. 4) For CABG in patients with normal baseline troponin values, elevations of cardiac biomarkers above the 99th percentile URL are indicative of periprocedural myocardial necrosis. By convention, increases of biomarkers >5x99th percentile URL plus either new pathological Q waves or new or imaging evidence of new loss of viable myocardium have been designated as defining CABG-related MI. 5) Pathological findings of an acute MI.

Datentyp

text

Alias

UMLS CUI-1

C1275835

Beschreibung

Indicate if the patient had an MI within 6 wk prior to the index procedure as evidenced by the following: 1.) Acute MI (<=7 d) manifested as a rise and fall of cardiac biomarkers (preferably troponin) with at least 1 value above the range of normal for your laboratory (above the 99th percentile of the URL) together with evidence of myocardial ischemia with at least 1 of the following: a. Ischemic symptoms b. Electrocardiographic changes indicative of new ischemia (new ST-T and/or T-wave changes or new LBBB) c. Development of pathological Q waves on the ECG d. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality 2.) Recent MI (>7 d) manifested by a. An MI meeting the criteria for an acute MI as documented in the medical record, or b. By any 1 of the following: 1. Development of new pathological Q waves with or without symptoms 2. Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract 3. In the absence of a nonischemic cause

Datentyp

boolean

Beschreibung

History of angina - Stable angina (CCS class, date of onset) - Unstable angina (date of onset) - Prior angina (currently asymptomatic)

Datentyp

text

Alias

UMLS CUI-1

C0455530

Beschreibung

Indicate history of prior Coronary Artery Bypass Graft (CABG) surgery, including the date or year of surgery. The total number of CABG procedures and the year of the most recent procedure may be helpful.

Datentyp

text

Alias

UMLS CUI-1

C1842251

Beschreibung

Prior PCI of any type (balloon angioplasty, atherectomy, stent, or other). Total number of PCI procedures and dates (years)

Datentyp

text

Alias

UMLS CUI-1

C1320647

Beschreibung

Indicate if the patient has a history of lower extremity PAD (from iliac to tibials). Excludes renal, coronary, cerebral, and mesenteric vessels and aneurysm. Major symptoms can include - Asymptomatic (confirmed by noninvasive diagnostic test) - Claudication relieved by rest - Ischemic rest pain - Tissue loss (including ischemic ulcer and/or gangrene) - Amputation for critical limb ischemia - Vascular reconstruction, bypass surgery, or percutaneous revascularization in the arteries of the lower extremities - Positive noninvasive test (eg, ABI <=0.90, ultrasound, MR or CT imaging demonstrating >50% diameter stenosis in any peripheral artery, ie, aorta, iliac, femoral, popliteal, tibial, peroneal)

Datentyp

boolean

Alias

UMLS CUI-1

C1881056

Beschreibung

Indicate if the patient has a history of aortic aneurysm. This can include - Thoracic aneurysm - Thoracoabdominal aneurysm - AAA Confirmed by ultrasound, CT, and/or MR imaging.

Datentyp

boolean

Alias

UMLS CUI-1

C0459854

Beschreibung

Indicate if the patient has a history of renal or mesenteric artery disease. This can include an abnormal imaging study such as duplex ultrasonography, MRA, CTA, or catheter-based contrast angiography demonstrating >50% diameter stenosis in the renal artery, celiac trunk, SMA, or IMA.

Datentyp

boolean

Beschreibung

Indicate if the patient has a documented history of TIA consisting of a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction. Note the following: - Right retinal - Right hemispheric - Left retinal - Left hemispheric - Vertebrobasilar - Unknown distribution

Datentyp

text

Alias

UMLS CUI-1

C0455536

Beschreibung

Indicate whether the patient has a history of stroke, which is defined as an acute episode of neurological dysfunction caused by focal or global brain, spinal cord, or retinal vascular injury as a result of hemorrhage or infarction. If present, record the type of stroke: - Ischemic - Intracerebral hemorrhage - Subarachnoid hemorrhage - Unknown If ischemic, list the most likely etiologies: - Large-artery atherosclerosis of the extracranial vessels (eg, carotid) - Large-artery atherosclerosis of the intracranial vessels (eg, middle cerebral artery stenosis) - Cardioembolism - Small-vessel occlusion (lacunar) - Ischemic stroke of other determined etiology (eg, arterial dissection) - Ischemic stroke of undetermined etiology

Datentyp

text

Alias

UMLS CUI-1

C0559159

Beschreibung

Indicate if the patient has a previous history of Congestive Heart Failure (CHF). This includes a previous hospital admission with a principal diagnosis of CHF. CHF is defined as documentation or report of any 2 of the following Framingham major criteria of heart failure: orthopnea/paroxysmal nocturnal dyspnea; or the description of rales, jugular venous distention, hepatojugular reflux, S3 gallop, or pulmonary edema on chest x-ray; or 1 of the major criteria plus 2 Framingham minor criteria, including dyspnea on exertion, nocturnal cough, ankle edema, pleural effusion, or tachycardia. A low ejection fraction without clinical evidence of heart failure does not qualify as heart failure. Include the year of onset if known.

Datentyp

text

Alias

UMLS CUI-1

C0455531

Beschreibung

NYHA classification scale

Datentyp

text

Alias

UMLS CUI-1

C1275491

Beschreibung

Indicate if the patient has a history of pulmonary insufficiency. Pulmonary insufficiency is defined as PaO2 of <60 mm Hg while breathing air or PaCO2 of >50 mm Hg.

Datentyp

boolean

Alias

UMLS CUI-1

C0340398

UMLS CUI-2

C0332119

Beschreibung

Current or previous history of chronic kidney disease. Chronic kidney disease is defined as either kidney damage or GFR <60 mL/min/1.73 m2 for >=3 mo. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Indicate the patient’s stage of disease: - Stage 0: No known kidney disease - Stage 1: Kidney damage with normal or high GFR >=90 mL/min/1.73 m2 - Stage 2: Kidney damage with mildly decreased GFR—60–89 mL/min/1.73 m2 - Stage 3: Moderately decreased GFR—30–59 mL/min/1.73 m2 - Stage 4: Severely decreased GFR—15–29 mL/min/1.73 m2 - Stage 5: Kidney failure—GFR <15 mL/min/1.73 m2 or on dialysis Year of onset (first diagnosis) may be helpful.

Datentyp

text

Alias

UMLS CUI-1

C3532472

Beschreibung

Height

Datentyp

float

Maßeinheiten

• cm

Alias

UMLS CUI [1]

C0005890

Beschreibung

Body weight

Datentyp

float

Maßeinheiten

• kg

Alias

UMLS CUI [1]

C0005910

Beschreibung

Body Mass Index

Datentyp

float

Maßeinheiten

• kg/m2

Alias

UMLS CUI [1]

C1305855

Beschreibung

Systolic

Datentyp

integer

Maßeinheiten

• mmHg

Alias

UMLS CUI [1]

C0871470

Beschreibung

Diastolic

Datentyp

integer

Maßeinheiten

• mmHg

Alias

UMLS CUI [1]

C0428883

Beschreibung

Heart rate

Datentyp

integer

Maßeinheiten

• bpm

Alias

UMLS CUI [1]

C0018810

Beschreibung

Cardiac rhythm

Datentyp

integer

Alias

UMLS CUI-1

C0232187

Beschreibung

Complete vascular examination: Carotid, upper, lower extremity pulses, auscultation of the neck for carotid bruits, auscultation of the abdomen and femoral arteries for bruits, palpation of the abdomen and popliteal fossa for aneurysms

Datentyp

text

Alias

UMLS CUI-1

C2053830

Beschreibung

Complete cardiac examination: Palpation and auscultation of the heart, assessing rate, rhythm, presence of murmur, presence of gallop (eg, S3 suggesting left ventricular dysfunction; S4 suggesting noncompliant left ventricle), notation of location of point of maximal intensity

Datentyp

text

Beschreibung

Limb edema. Note the presence/absence of lower extremity (less commonly, upper extremity) edema, including location, extent, and pitting versus nonpitting.

Datentyp

text

Alias

UMLS CUI-1

C0085649

Beschreibung

Include RBC, WBC, and platelet counts: 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

text

Alias

UMLS CUI-1

C0009555

Beschreibung

Hemoglobin

Datentyp

float

Maßeinheiten

• g/dL

Alias

UMLS CUI [1]

C0019046

Beschreibung

Hematocrit

Datentyp

float

Maßeinheiten

• %

Alias

UMLS CUI [1]

C0518014

Beschreibung

Glucose

Datentyp

float

Maßeinheiten

• mg/dl

Alias

UMLS CUI [1]

C0202042

Beschreibung

BUN

Datentyp

float

Maßeinheiten

• mg/dL

Alias

UMLS CUI [1]

C0005845

Beschreibung

Creatinine

Datentyp

float

Maßeinheiten

• mg/dL

Alias

UMLS CUI [1]

C0201976

Beschreibung

Indicate estimated or actual GFR in milliliters per minute per 1.73 meters squared.

Datentyp

float

Maßeinheiten

• ml/(min*1,73m2)

Alias

UMLS CUI-1

C0017654

Beschreibung

Sodium

Datentyp

float

Maßeinheiten

• mmol/L

Alias

UMLS CUI [1]

C0337443

Beschreibung

Potassium

Datentyp

float

Maßeinheiten

• mmol/l

Alias

UMLS CUI [1]

C0202194

Beschreibung

Hemogloblin A1C

Datentyp

float

Maßeinheiten

• %

Alias

UMLS CUI [1]

C0019018

Beschreibung

Prothrombin time Measured in seconds. Report INR as ratio.

Datentyp

float

Maßeinheiten

• s

Alias

UMLS CUI-1

C0033707

Beschreibung

Partial thromboplastin time Indicate whether activators used (aPTT) or not (PTT). Measured in seconds.

Datentyp

float

Maßeinheiten

• s

Alias

UMLS CUI-1

C0030605

Beschreibung

Total cholesterol 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Maßeinheiten

• mg/dL

Alias

UMLS CUI [1]

C1445957

Beschreibung

LDL

Datentyp

float

Maßeinheiten

• mg/dL

Alias

UMLS CUI [1]

C0428474

Beschreibung

HDL

Datentyp

float

Maßeinheiten

• mg/dL

Alias

UMLS CUI [1]

C0428472

Beschreibung

Triglycerides

Datentyp

float

Maßeinheiten

• mg/dL

Alias

UMLS CUI [1]

C0202236

Beschreibung

hs-CRP 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0201657

Beschreibung

ESR 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0086250

Beschreibung

Calcium

Datentyp

float

Maßeinheiten

• mmol/l

Alias

UMLS CUI [1]

C0201925

Beschreibung

Phosphorus 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0523826

Beschreibung

Magnesium 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0373675

Beschreibung

TSH 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0202230

Beschreibung

BNP or N-terminal BNP 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C1095989

Beschreibung

AST (SGOT)

Datentyp

float

Maßeinheiten

• U/L

Alias

UMLS CUI [1]

C0201899

Beschreibung

ALT (SGPT)

Datentyp

float

Maßeinheiten

• U/L

Alias

UMLS CUI [1]

C0201836

Beschreibung

The upper limit of normal of total CK as defined by individual hospital laboratory standards. Units of CK and type of units should be noted (eg, IU, ng/dL, kCat/L). All CK values during hospitalization should be noted; include units, date, and time.

Datentyp

float

Alias

UMLS CUI-1

C0201973

Beschreibung

Indicate the upper limit of normal (usually the 99th percentile of a normal population) and units (eg, ng/dL). All troponin T values during hospitalization should be noted; include units, date, and time.

Datentyp

float

Alias

UMLS CUI-1

C1141947

Beschreibung

Indicate the upper limit of normal (usually the 99th percentile of a normal population) and units (eg, ng/dL). All troponin I values during hospitalization should be noted; include units, date, and time.

Datentyp

float

Alias

UMLS CUI-1

C0920210

Beschreibung

Homocysteine 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C2242817

Beschreibung

Vitamin B12 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0202252

Beschreibung

Folate 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0523631

Beschreibung

Prothrombin 20210 gene mutation 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C1273306

Beschreibung

Protein C activity 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C1255234

Beschreibung

Protein S activity 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0919678

Beschreibung

Antithrombin III 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C2825854

Beschreibung

Anticardiolipin antibody 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C0201535

Beschreibung

Lupus anticoagulant 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)

Datentyp

float

Alias

UMLS CUI-1

C1142517

Beschreibung

Aspirin. Note specific dose.

Datentyp

integer

Alias

UMLS CUI-1

C0004057

Beschreibung

Clopidogrel. Note specific dose.

Datentyp

integer

Alias

UMLS CUI-1

C0070166

Beschreibung

Prasugrel. Note specific dose.

Datentyp

integer

Alias

UMLS CUI-1

C1620287

Beschreibung

Other P2Y12 antagonists (Purinergic P2Y12 Receptor Antagonists). Note specific drug and dose.

Datentyp

integer

Alias

UMLS CUI-1

C2936585

Beschreibung

Dipyridamole. Note specific dose.

Datentyp

integer

Alias

UMLS CUI-1

C0012582

Beschreibung

Other antiplatelet drugs. Note specific drug and dose.

Datentyp

text

Beschreibung

Unfractionated heparin. Note specific dose.

Datentyp

integer

Alias

UMLS CUI-1

C2825026

Beschreibung

Low–molecular-weight heparin. Note specific drug and dose.

Datentyp

integer

Alias

UMLS CUI-1

C0019139

Beschreibung

Fondaparinux. Note specific dose.

Datentyp

integer

Alias

UMLS CUI-1

C1098510

Beschreibung

Other factor Xa inhibitor. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C2825027

Beschreibung

Direct thrombin inhibitor. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C3536847

Beschreibung

Warfarin. Indicate whether this drug has been prescribed; note INR.

Datentyp

text

Alias

UMLS CUI-1

C0043031

Beschreibung

Other anticoagulant drug. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C0003280

Beschreibung

Antihypertensive drugs. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C0003364

Beschreibung

Statins and lipid-control agents. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C0360714

Beschreibung

Drugs for diabetes. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C3653344

Beschreibung

Drugs to aid in smoking cessation. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C1095963

Beschreibung

Antiarrhythmic drugs. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C0003195

Beschreibung

Heart failure medications. Note specific drug and dose.

Datentyp

text

Alias

UMLS CUI-1

C0018801

UMLS CUI-2

C0013227

Beschreibung

Drugs for symptoms of PAD. Note specific drug and dose.

Datentyp

text

Beschreibung

Noncardiovascular medications. Note the specific drug and dose.

Datentyp

text

Beschreibung

Medication allergy. Specify the medication and type of reaction

Datentyp

text

Alias

UMLS CUI-1

C0013182

Beschreibung

Medication side effect. Describe the side effect and whether the medication was stopped.

Datentyp

text

Alias

UMLS CUI-1

C0041755