ID

20136

Beschrijving

Medical History Form converted to ODM format. Routine documentation of university hospital muenster. Publication granted by Prof. Dr. Dr. Kleinheinz

Trefwoorden

  1. 30-11-16 30-11-16 -
  2. 08-02-17 08-02-17 -
Geüploaded op

8 februari 2017

DOI

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Licentie

Creative Commons BY-NC 3.0

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Oral and maxillofacial surgery medical history form UKM

Medical history

  1. StudyEvent: ODM
    1. Medical history
Patientendaten
Beschrijving

Patientendaten

Name des Patienten
Beschrijving

Patient name

Datatype

integer

Alias
UMLS CUI [1]
C1299487
Diagnose
Beschrijving

Diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Geburtstag Patient
Beschrijving

Patient date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Familienanamnese
Beschrijving

Familienanamnese

Neoplasien
Beschrijving

Neoplasia

Datatype

integer

Alias
UMLS CUI [1]
C1882062
Spalten
Beschrijving

Cleft Palate

Datatype

integer

Alias
UMLS CUI [1]
C0008925
Sonst. Erkrankungen
Beschrijving

Other disease

Datatype

integer

Alias
UMLS CUI [1]
C2359476
Allgemeine Anamnese
Beschrijving

Allgemeine Anamnese

Allgemeine Anamnese
Beschrijving

Medical history

Datatype

integer

Alias
UMLS CUI [1]
C0262926
Beruf
Beschrijving

Occupation

Datatype

integer

Alias
UMLS CUI [1]
C0028811
Medikamente z. Zt.
Beschrijving

Medication

Datatype

integer

Alias
UMLS CUI [1]
C0013227
Spezielle Anamnese
Beschrijving

Spezielle Anamnese

Medical history
Beschrijving

Medical history

Datatype

integer

Alias
UMLS CUI [1]
C1704706
Allgemeiner Befund
Beschrijving

Allgemeiner Befund

Allgemeinzustand
Beschrijving

General condition

Datatype

integer

Alias
UMLS CUI [1]
C1142435
Haut
Beschrijving

Skin

Datatype

integer

Alias
UMLS CUI [1]
C1123023
Lymphknoten
Beschrijving

Lymph nodes

Datatype

integer

Alias
UMLS CUI [1]
C0024204
Gewicht
Beschrijving

Weight

Datatype

integer

Maateenheden
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Diabetes
Beschrijving

Diabetes

Datatype

integer

Alias
UMLS CUI [1]
C0011849
Blutungsneigung
Beschrijving

Bleeding tendency

Datatype

integer

Alias
UMLS CUI [1]
C1458140
Thrombose
Beschrijving

Thrombosis

Datatype

integer

Alias
UMLS CUI [1]
C0040053
Allergie
Beschrijving

Allergies

Datatype

integer

Alias
UMLS CUI [1]
C0020517
Dyspnoe
Beschrijving

Dyspnoe

Datatype

integer

Alias
UMLS CUI [1]
C0013404
Zyanose
Beschrijving

Cyanosis

Datatype

integer

Alias
UMLS CUI [1]
C0010520
Ödeme
Beschrijving

Edema

Datatype

integer

Alias
UMLS CUI [1]
C0013604
Nykturie
Beschrijving

Nocturia

Datatype

integer

Alias
UMLS CUI [1]
C0028734
Abusus
Beschrijving

Substance abuse

Datatype

integer

Alias
UMLS CUI [1]
C0038586
Alkohol
Beschrijving

Alcohol

Datatype

integer

Alias
UMLS CUI [1]
C0001948
Nikotin
Beschrijving

Nicotin

Datatype

integer

Alias
UMLS CUI [1]
C0028040
Thorax
Beschrijving

Thorax

Alias
UMLS CUI-1
C0817096
Lungen: Grenzen
Beschrijving

Margin of lung

Datatype

integer

Alias
UMLS CUI [1]
C1282028
Klopfschall Lunge
Beschrijving

Ppercussion of lung

Datatype

integer

Alias
UMLS CUI [1]
C1291006
Atemgeräusch
Beschrijving

Respiratory Sounds

Datatype

integer

Alias
UMLS CUI [1]
C0035234
Herz: Töne
Beschrijving

Heart sounds

Datatype

integer

Alias
UMLS CUI [1]
C0018820
Herzaktion
Beschrijving

Heartbeat

Datatype

integer

Alias
UMLS CUI [1]
C0425583
RR
Beschrijving

RR

Datatype

integer

Alias
UMLS CUI [1]
C0005823
Periphere Pulse
Beschrijving

Pulse

Datatype

integer

Alias
UMLS CUI [1]
C0232117
Mammae
Beschrijving

Mammae

Datatype

integer

Alias
UMLS CUI [1]
C0006141
Abdomen
Beschrijving

Abdomen

Alias
UMLS CUI-1
C0000726
Leber
Beschrijving

Liver

Datatype

integer

Alias
UMLS CUI [1]
C0023884
Milz
Beschrijving

Spleen

Datatype

integer

Alias
UMLS CUI [1]
C0037993
Druckschmerz
Beschrijving

Pain pressure

Datatype

integer

Alias
UMLS CUI [1]
C3647129
Bruchpforten
Beschrijving

Hernia

Datatype

integer

Alias
UMLS CUI [1]
C0019270
Narben
Beschrijving

Scar Tissue

Datatype

integer

Alias
UMLS CUI [1]
C0241158
Extremitäten
Beschrijving

Extremitäten

Extremitäten
Beschrijving

Extremities

Datatype

integer

Alias
UMLS CUI [1]
C0015385
Nervensystem
Beschrijving

Nervensystem

Nervensystem
Beschrijving

Nervous system

Datatype

integer

Alias
UMLS CUI [1]
C0027763
Wirbelsäule
Beschrijving

Wirbelsäule

Wirbelsäule
Beschrijving

Entire vertebral column

Datatype

integer

Alias
UMLS CUI [1]
C1267072
Spezieller Befund
Beschrijving

Spezieller Befund

Extraoral
Beschrijving

Extraoral

Datatype

integer

Alias
UMLS CUI [1]
C0442089
Motilität der Augen
Beschrijving

Ocular motility observations

Datatype

integer

Alias
UMLS CUI [1]
C0549100
Doppelbilder
Beschrijving

Diplopia

Datatype

integer

Alias
UMLS CUI [1]
C0012569
N. V
Beschrijving

Trigeminal nerve structure

Datatype

integer

Alias
UMLS CUI [1]
C0040996
N. VII
Beschrijving

Facial nerve structure

Datatype

integer

Alias
UMLS CUI [1]
C0015462
Lymphknoten
Beschrijving

Lymph nodes

Datatype

integer

Alias
UMLS CUI [1]
C0024204
SKD:
Beschrijving

Mouth opening

Datatype

integer

Maateenheden
  • mm
Alias
UMLS CUI [1]
C0226895
mm
Palpation: Schmerz
Beschrijving

Pain in head

Datatype

integer

Alias
UMLS CUI [1]
C2370967
Schleimhaut
Beschrijving

Mucosa

Datatype

integer

Alias
UMLS CUI [1]
C0026724
Zunge
Beschrijving

Tongue

Datatype

integer

Alias
UMLS CUI [1]
C0040408
Rachenring
Beschrijving

Waldeyer's ring

Datatype

integer

Alias
UMLS CUI [1]
C0459892
Zahnstein
Beschrijving

Dental Calculus

Datatype

integer

Alias
UMLS CUI [1]
C0011330
Parodontopathien
Beschrijving

Periodontal Diseases

Datatype

integer

Alias
UMLS CUI [1]
C0031090
Röntgenbefund
Beschrijving

Röntgenbefund

Röntgenbefund
Beschrijving

X-rays results

Datatype

integer

Alias
UMLS CUI [1]
C0850567
Footer module
Beschrijving

Footer module

Datum
Beschrijving

Date

Datatype

integer

Alias
UMLS CUI [1]
C0011008
Unterschrift
Beschrijving

Signature

Datatype

integer

Alias
UMLS CUI [1]
C1519316

Similar models

Medical history

  1. StudyEvent: ODM
    1. Medical history
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Patientendaten
Patient name
Item
Name des Patienten
integer
C1299487 (UMLS CUI [1])
Diagnosis
Item
Diagnose
integer
C0011900 (UMLS CUI [1])
Patient date of birth
Item
Geburtstag Patient
date
C0421451 (UMLS CUI [1])
Item Group
Familienanamnese
Neoplasia
Item
Neoplasien
integer
C1882062 (UMLS CUI [1])
Cleft Palate
Item
Spalten
integer
C0008925 (UMLS CUI [1])
Other disease
Item
Sonst. Erkrankungen
integer
C2359476 (UMLS CUI [1])
Item Group
Allgemeine Anamnese
Medical history
Item
Allgemeine Anamnese
integer
C0262926 (UMLS CUI [1])
Occupation
Item
Beruf
integer
C0028811 (UMLS CUI [1])
Medication
Item
Medikamente z. Zt.
integer
C0013227 (UMLS CUI [1])
Item Group
Spezielle Anamnese
Medical history
Item
integer
C1704706 (UMLS CUI [1])
Item Group
Allgemeiner Befund
General condition
Item
Allgemeinzustand
integer
C1142435 (UMLS CUI [1])
Skin
Item
Haut
integer
C1123023 (UMLS CUI [1])
Lymph nodes
Item
Lymphknoten
integer
C0024204 (UMLS CUI [1])
Weight
Item
Gewicht
integer
C0005910 (UMLS CUI [1])
Diabetes
Item
Diabetes
integer
C0011849 (UMLS CUI [1])
Bleeding tendency
Item
Blutungsneigung
integer
C1458140 (UMLS CUI [1])
Thrombosis
Item
Thrombose
integer
C0040053 (UMLS CUI [1])
Allergies
Item
Allergie
integer
C0020517 (UMLS CUI [1])
Dyspnoe
Item
Dyspnoe
integer
C0013404 (UMLS CUI [1])
Cyanosis
Item
Zyanose
integer
C0010520 (UMLS CUI [1])
Edema
Item
Ödeme
integer
C0013604 (UMLS CUI [1])
Nocturia
Item
Nykturie
integer
C0028734 (UMLS CUI [1])
Substance abuse
Item
Abusus
integer
C0038586 (UMLS CUI [1])
Alcohol
Item
Alkohol
integer
C0001948 (UMLS CUI [1])
Nicotin
Item
Nikotin
integer
C0028040 (UMLS CUI [1])
Item Group
Thorax
C0817096 (UMLS CUI-1)
Margin of lung
Item
Lungen: Grenzen
integer
C1282028 (UMLS CUI [1])
Ppercussion of lung
Item
Klopfschall Lunge
integer
C1291006 (UMLS CUI [1])
Respiratory Sounds
Item
Atemgeräusch
integer
C0035234 (UMLS CUI [1])
Heart sounds
Item
Herz: Töne
integer
C0018820 (UMLS CUI [1])
Heartbeat
Item
Herzaktion
integer
C0425583 (UMLS CUI [1])
RR
Item
RR
integer
C0005823 (UMLS CUI [1])
Pulse
Item
Periphere Pulse
integer
C0232117 (UMLS CUI [1])
Mammae
Item
Mammae
integer
C0006141 (UMLS CUI [1])
Item Group
Abdomen
C0000726 (UMLS CUI-1)
Liver
Item
Leber
integer
C0023884 (UMLS CUI [1])
Spleen
Item
Milz
integer
C0037993 (UMLS CUI [1])
Pain pressure
Item
Druckschmerz
integer
C3647129 (UMLS CUI [1])
Hernia
Item
Bruchpforten
integer
C0019270 (UMLS CUI [1])
Scar Tissue
Item
Narben
integer
C0241158 (UMLS CUI [1])
Item Group
Extremitäten
Extremities
Item
Extremitäten
integer
C0015385 (UMLS CUI [1])
Item Group
Nervensystem
Nervous system
Item
Nervensystem
integer
C0027763 (UMLS CUI [1])
Item Group
Wirbelsäule
Entire vertebral column
Item
Wirbelsäule
integer
C1267072 (UMLS CUI [1])
Item Group
Spezieller Befund
Extraoral
Item
Extraoral
integer
C0442089 (UMLS CUI [1])
Ocular motility observations
Item
Motilität der Augen
integer
C0549100 (UMLS CUI [1])
Diplopia
Item
Doppelbilder
integer
C0012569 (UMLS CUI [1])
Trigeminal nerve structure
Item
N. V
integer
C0040996 (UMLS CUI [1])
Facial nerve structure
Item
N. VII
integer
C0015462 (UMLS CUI [1])
Lymph nodes
Item
Lymphknoten
integer
C0024204 (UMLS CUI [1])
Mouth opening
Item
SKD:
integer
C0226895 (UMLS CUI [1])
Item
Palpation: Schmerz
integer
C2370967 (UMLS CUI [1])
Code List
Palpation: Schmerz
CL Item
Temporomandibular joint lateral (1)
C0039493 (UMLS CUI-1)
CL Item
Temporomandibular joint posterior (2)
C0039493 (UMLS CUI-1)
CL Item
Temporalis muscle (3)
C0039487 (UMLS CUI-1)
CL Item
Masseter muscle  (4)
C0024876 (UMLS CUI-1)
CL Item
Suboccipital muscle (5)
C0448352 (UMLS CUI-1)
CL Item
Sternocleidomastoid muscle (6)
C0224153 (UMLS CUI-1)
CL Item
M. digastricus (7)
C0224155 (UMLS CUI-1)
CL Item
M. pterygoideus med. (8)
C0224146 (UMLS CUI-1)
CL Item
M. pterygoideus lat. (9)
C0224145 (UMLS CUI-1)
Mucosa
Item
Schleimhaut
integer
C0026724 (UMLS CUI [1])
Tongue
Item
Zunge
integer
C0040408 (UMLS CUI [1])
Waldeyer's ring
Item
Rachenring
integer
C0459892 (UMLS CUI [1])
Dental Calculus
Item
Zahnstein
integer
C0011330 (UMLS CUI [1])
Periodontal Diseases
Item
Parodontopathien
integer
C0031090 (UMLS CUI [1])
Item Group
Röntgenbefund
X-rays results
Item
Röntgenbefund
integer
C0850567 (UMLS CUI [1])
Item Group
Footer module
Date
Item
Datum
integer
C0011008 (UMLS CUI [1])
Signature
Item
Unterschrift
integer
C1519316 (UMLS CUI [1])

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