ID

20136

Beskrivning

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

Nyckelord

  1. 2016-11-30 2016-11-30 -
  2. 2017-02-08 2017-02-08 -
Uppladdad den

8 februari 2017

DOI

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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
Patient demographics
Beskrivning

Patient demographics

Patient name
Beskrivning

Patient name

Datatyp

integer

Alias
UMLS CUI [1]
C1299487
Diagnosis
Beskrivning

Diagnosis

Datatyp

integer

Alias
UMLS CUI [1]
C0011900
Patient date of birth
Beskrivning

Patient date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Family history
Beskrivning

Family history

Neoplasia
Beskrivning

Neoplasia

Datatyp

integer

Alias
UMLS CUI [1]
C1882062
Cleft Palate
Beskrivning

Cleft Palate

Datatyp

integer

Alias
UMLS CUI [1]
C0008925
Other disease
Beskrivning

Other disease

Datatyp

integer

Alias
UMLS CUI [1]
C2359476
General medical history
Beskrivning

General medical history

Medical history
Beskrivning

Medical history

Datatyp

integer

Alias
UMLS CUI [1]
C0262926
Occupation
Beskrivning

Occupation

Datatyp

integer

Alias
UMLS CUI [1]
C0028811
Medication
Beskrivning

Medication

Datatyp

integer

Alias
UMLS CUI [1]
C0013227
Special medical history
Beskrivning

Special medical history

Medical history
Beskrivning

Medical history

Datatyp

integer

Alias
UMLS CUI [1]
C1704706
Medical report
Beskrivning

Medical report

General condition
Beskrivning

General condition

Datatyp

integer

Alias
UMLS CUI [1]
C1142435
Skin
Beskrivning

Skin

Datatyp

integer

Alias
UMLS CUI [1]
C1123023
Lymph nodes
Beskrivning

Lymph nodes

Datatyp

integer

Alias
UMLS CUI [1]
C0024204
Weight
Beskrivning

Weight

Datatyp

integer

Måttenheter
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Diabetes
Beskrivning

Diabetes

Datatyp

integer

Alias
UMLS CUI [1]
C0011849
Bleeding tendency
Beskrivning

Bleeding tendency

Datatyp

integer

Alias
UMLS CUI [1]
C1458140
Thrombosis
Beskrivning

Thrombosis

Datatyp

integer

Alias
UMLS CUI [1]
C0040053
Allergies
Beskrivning

Allergies

Datatyp

integer

Alias
UMLS CUI [1]
C0020517
Dyspnoe
Beskrivning

Dyspnoe

Datatyp

integer

Alias
UMLS CUI [1]
C0013404
Cyanosis
Beskrivning

Cyanosis

Datatyp

integer

Alias
UMLS CUI [1]
C0010520
Edema
Beskrivning

Edema

Datatyp

integer

Alias
UMLS CUI [1]
C0013604
Nocturia
Beskrivning

Nocturia

Datatyp

integer

Alias
UMLS CUI [1]
C0028734
Substance abuse
Beskrivning

Substance abuse

Datatyp

integer

Alias
UMLS CUI [1]
C0038586
Alcohol
Beskrivning

Alcohol

Datatyp

integer

Alias
UMLS CUI [1]
C0001948
Nicotin
Beskrivning

Nicotin

Datatyp

integer

Alias
UMLS CUI [1]
C0028040
Chest
Beskrivning

Chest

Alias
UMLS CUI-1
C0817096
Margin of lung
Beskrivning

Margin of lung

Datatyp

integer

Alias
UMLS CUI [1]
C1282028
Ppercussion of lung
Beskrivning

Ppercussion of lung

Datatyp

integer

Alias
UMLS CUI [1]
C1291006
Respiratory Sounds
Beskrivning

Respiratory Sounds

Datatyp

integer

Alias
UMLS CUI [1]
C0035234
Heart sounds
Beskrivning

Heart sounds

Datatyp

integer

Alias
UMLS CUI [1]
C0018820
Heartbeat
Beskrivning

Heartbeat

Datatyp

integer

Alias
UMLS CUI [1]
C0425583
RR
Beskrivning

RR

Datatyp

integer

Alias
UMLS CUI [1]
C0005823
Pulse
Beskrivning

Pulse

Datatyp

integer

Alias
UMLS CUI [1]
C0232117
Mammae
Beskrivning

Mammae

Datatyp

integer

Alias
UMLS CUI [1]
C0006141
Abdomen
Beskrivning

Abdomen

Alias
UMLS CUI-1
C0000726
Liver
Beskrivning

Liver

Datatyp

integer

Alias
UMLS CUI [1]
C0023884
Spleen
Beskrivning

Spleen

Datatyp

integer

Alias
UMLS CUI [1]
C0037993
Pain pressure
Beskrivning

Pain pressure

Datatyp

integer

Alias
UMLS CUI [1]
C3647129
Hernia
Beskrivning

Hernia

Datatyp

integer

Alias
UMLS CUI [1]
C0019270
Scar Tissue
Beskrivning

Scar Tissue

Datatyp

integer

Alias
UMLS CUI [1]
C0241158
Extremities
Beskrivning

Extremities

Extremities
Beskrivning

Extremities

Datatyp

integer

Alias
UMLS CUI [1]
C0015385
Nervous system
Beskrivning

Nervous system

Nervous system
Beskrivning

Nervous system

Datatyp

integer

Alias
UMLS CUI [1]
C0027763
Spinal column
Beskrivning

Spinal column

Entire vertebral column
Beskrivning

Entire vertebral column

Datatyp

integer

Alias
UMLS CUI [1]
C1267072
Special medical report
Beskrivning

Special medical report

Extraoral
Beskrivning

Extraoral

Datatyp

integer

Alias
UMLS CUI [1]
C0442089
Ocular motility observations
Beskrivning

Ocular motility observations

Datatyp

integer

Alias
UMLS CUI [1]
C0549100
Diplopia
Beskrivning

Diplopia

Datatyp

integer

Alias
UMLS CUI [1]
C0012569
Trigeminal nerve structure
Beskrivning

Trigeminal nerve structure

Datatyp

integer

Alias
UMLS CUI [1]
C0040996
Facial nerve structure
Beskrivning

Facial nerve structure

Datatyp

integer

Alias
UMLS CUI [1]
C0015462
Lymph nodes
Beskrivning

Lymph nodes

Datatyp

integer

Alias
UMLS CUI [1]
C0024204
Mouth opening
Beskrivning

Mouth opening

Datatyp

integer

Måttenheter
  • mm
Alias
UMLS CUI [1]
C0226895
mm
Pain in head
Beskrivning

Pain in head

Datatyp

integer

Alias
UMLS CUI [1]
C2370967
Mucosa
Beskrivning

Mucosa

Datatyp

integer

Alias
UMLS CUI [1]
C0026724
Tongue
Beskrivning

Tongue

Datatyp

integer

Alias
UMLS CUI [1]
C0040408
Waldeyer's ring
Beskrivning

Waldeyer's ring

Datatyp

integer

Alias
UMLS CUI [1]
C0459892
Dental Calculus
Beskrivning

Dental Calculus

Datatyp

integer

Alias
UMLS CUI [1]
C0011330
Periodontal Diseases
Beskrivning

Periodontal Diseases

Datatyp

integer

Alias
UMLS CUI [1]
C0031090
X-rays results
Beskrivning

X-rays results

X-rays results
Beskrivning

X-rays results

Datatyp

integer

Alias
UMLS CUI [1]
C0850567
Footer module
Beskrivning

Footer module

Date
Beskrivning

Date

Datatyp

integer

Alias
UMLS CUI [1]
C0011008
Signature
Beskrivning

Signature

Datatyp

integer

Alias
UMLS CUI [1]
C1519316

Similar models

Medical history

  1. StudyEvent: ODM
    1. Medical history
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient demographics
Patient name
Item
Patient name
integer
C1299487 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Patient date of birth
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Item Group
Family history
Neoplasia
Item
Neoplasia
integer
C1882062 (UMLS CUI [1])
Cleft Palate
Item
Cleft Palate
integer
C0008925 (UMLS CUI [1])
Other disease
Item
Other disease
integer
C2359476 (UMLS CUI [1])
Item Group
General medical history
Medical history
Item
Medical history
integer
C0262926 (UMLS CUI [1])
Occupation
Item
Occupation
integer
C0028811 (UMLS CUI [1])
Medication
Item
Medication
integer
C0013227 (UMLS CUI [1])
Item Group
Special medical history
Medical history
Item
Medical history
integer
C1704706 (UMLS CUI [1])
Item Group
Medical report
General condition
Item
General condition
integer
C1142435 (UMLS CUI [1])
Skin
Item
Skin
integer
C1123023 (UMLS CUI [1])
Lymph nodes
Item
Lymph nodes
integer
C0024204 (UMLS CUI [1])
Weight
Item
Weight
integer
C0005910 (UMLS CUI [1])
Diabetes
Item
Diabetes
integer
C0011849 (UMLS CUI [1])
Bleeding tendency
Item
Bleeding tendency
integer
C1458140 (UMLS CUI [1])
Thrombosis
Item
Thrombosis
integer
C0040053 (UMLS CUI [1])
Allergies
Item
Allergies
integer
C0020517 (UMLS CUI [1])
Dyspnoe
Item
Dyspnoe
integer
C0013404 (UMLS CUI [1])
Cyanosis
Item
Cyanosis
integer
C0010520 (UMLS CUI [1])
Edema
Item
Edema
integer
C0013604 (UMLS CUI [1])
Nocturia
Item
Nocturia
integer
C0028734 (UMLS CUI [1])
Substance abuse
Item
Substance abuse
integer
C0038586 (UMLS CUI [1])
Alcohol
Item
Alcohol
integer
C0001948 (UMLS CUI [1])
Nicotin
Item
Nicotin
integer
C0028040 (UMLS CUI [1])
Item Group
Chest
C0817096 (UMLS CUI-1)
Margin of lung
Item
Margin of lung
integer
C1282028 (UMLS CUI [1])
Ppercussion of lung
Item
Ppercussion of lung
integer
C1291006 (UMLS CUI [1])
Respiratory Sounds
Item
Respiratory Sounds
integer
C0035234 (UMLS CUI [1])
Heart sounds
Item
Heart sounds
integer
C0018820 (UMLS CUI [1])
Heartbeat
Item
Heartbeat
integer
C0425583 (UMLS CUI [1])
RR
Item
RR
integer
C0005823 (UMLS CUI [1])
Pulse
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Mammae
Item
Mammae
integer
C0006141 (UMLS CUI [1])
Item Group
Abdomen
C0000726 (UMLS CUI-1)
Liver
Item
Liver
integer
C0023884 (UMLS CUI [1])
Spleen
Item
Spleen
integer
C0037993 (UMLS CUI [1])
Pain pressure
Item
Pain pressure
integer
C3647129 (UMLS CUI [1])
Hernia
Item
Hernia
integer
C0019270 (UMLS CUI [1])
Scar Tissue
Item
Scar Tissue
integer
C0241158 (UMLS CUI [1])
Item Group
Extremities
Extremities
Item
Extremities
integer
C0015385 (UMLS CUI [1])
Item Group
Nervous system
Nervous system
Item
Nervous system
integer
C0027763 (UMLS CUI [1])
Item Group
Spinal column
Entire vertebral column
Item
Entire vertebral column
integer
C1267072 (UMLS CUI [1])
Item Group
Special medical report
Extraoral
Item
Extraoral
integer
C0442089 (UMLS CUI [1])
Ocular motility observations
Item
Ocular motility observations
integer
C0549100 (UMLS CUI [1])
Diplopia
Item
Diplopia
integer
C0012569 (UMLS CUI [1])
Trigeminal nerve structure
Item
Trigeminal nerve structure
integer
C0040996 (UMLS CUI [1])
Facial nerve structure
Item
Facial nerve structure
integer
C0015462 (UMLS CUI [1])
Lymph nodes
Item
Lymph nodes
integer
C0024204 (UMLS CUI [1])
Mouth opening
Item
Mouth opening
integer
C0226895 (UMLS CUI [1])
Item
Pain in head
integer
C2370967 (UMLS CUI [1])
Code List
Pain in head
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
Mucosa
integer
C0026724 (UMLS CUI [1])
Tongue
Item
Tongue
integer
C0040408 (UMLS CUI [1])
Waldeyer's ring
Item
Waldeyer's ring
integer
C0459892 (UMLS CUI [1])
Dental Calculus
Item
Dental Calculus
integer
C0011330 (UMLS CUI [1])
Periodontal Diseases
Item
Periodontal Diseases
integer
C0031090 (UMLS CUI [1])
Item Group
X-rays results
X-rays results
Item
X-rays results
integer
C0850567 (UMLS CUI [1])
Item Group
Footer module
Date
Item
Date
integer
C0011008 (UMLS CUI [1])
Signature
Item
Signature
integer
C1519316 (UMLS CUI [1])

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