ID

20591

Beschrijving

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form Name: Poliklinik Anamnese

Trefwoorden

  1. 05-03-17 05-03-17 -
Geüploaded op

5 maart 2017

DOI

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Licentie

Creative Commons BY-NC 3.0

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Polyclinic Medical History University Hospital Cologne

Polyclinic Medical History University Hospital Cologne

Patientendaten
Beschrijving

Patientendaten

Alias
UMLS CUI-1
C2707520
Name:
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Vorname:
Beschrijving

Surname

Datatype

text

Alias
UMLS CUI [1]
C0421448
Geb.-Datum:
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Fallnummer.:
Beschrijving

Case number

Datatype

integer

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C0600091
Datum
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Uhrzeit
Beschrijving

Time

Datatype

time

Alias
UMLS CUI [1]
C0040223
Anamnese durch
Beschrijving

Investigator

Datatype

text

Alias
UMLS CUI [1]
C2826892
Vorstellung
Beschrijving

Patient referral

Datatype

integer

Alias
UMLS CUI [1]
C0034927
Frauenarzt
Beschrijving

Gynecologist

Datatype

text

Alias
UMLS CUI [1]
C0237419
Hausarzt
Beschrijving

General Practitioners

Datatype

text

Alias
UMLS CUI [1]
C0017319
Beruf
Beschrijving

Occupations

Datatype

text

Alias
UMLS CUI [1]
C0028811
Tel. Pat./ Angehörige
Beschrijving

Telephone Number

Datatype

text

Alias
UMLS CUI [1]
C1515258
Tel. Pat./ Angehörige Mobil:
Beschrijving

Telephone Number

Datatype

text

Alias
UMLS CUI [1]
C1515258
Vitalzeichen
Beschrijving

Vitalzeichen

Alias
UMLS CUI-1
C0518766
RR systolisch
Beschrijving

Systolic blood pressure

Datatype

float

Maateenheden
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
RR diastolisch
Beschrijving

Diastolic blood pressure

Datatype

float

Maateenheden
  • mmHg
Alias
UMLS CUI [1]
C0428883
mmHg
Pulse
Beschrijving

Heart rate

Datatype

float

Maateenheden
  • .min
Alias
UMLS CUI [1]
C0018810
.min
Temp
Beschrijving

Body temperature

Datatype

float

Maateenheden
  • C.
Alias
UMLS CUI [1]
C0886414
C.
betaHCG
Beschrijving

hcg

Datatype

float

Alias
UMLS CUI [1]
C0428402
U-Stix
Beschrijving

Urine Testing

Datatype

integer

Alias
UMLS CUI [1,1]
C0200354
UMLS CUI [1,2]
C0456984
Sonstiges
Beschrijving

Specification Of "Other"

Datatype

text

Alias
UMLS CUI [1]
C1521902
Anamnese
Beschrijving

Anamnese

Alias
UMLS CUI-1
C0262926
Familienanamnese
Beschrijving

Family History

Datatype

boolean

Alias
UMLS CUI [1]
C0241889
Familienanamnese
Beschrijving

Specification

Datatype

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C2348235
Vorerkrankungen
Beschrijving

Comorbidity

Datatype

boolean

Alias
UMLS CUI [1]
C0009488
Vorerkrankungen
Beschrijving

Specification

Datatype

text

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C2348235
Medikamente (Substanz, Dosierung)
Beschrijving

Medikamente (Substanz, Dosierung)

Alias
UMLS CUI-1
C0013227
Präparat
Beschrijving

Pharmaceutical Preparations

Datatype

text

Alias
UMLS CUI [1]
C0013227
Dosis
Beschrijving

dose

Datatype

text

Alias
UMLS CUI [1]
C3174092
Operationen
Beschrijving

Operationen

Alias
UMLS CUI-1
C0543467
Jahr
Beschrijving

Year

Datatype

partialDate

Alias
UMLS CUI [1]
C0439234
Operation
Beschrijving

Surgical Procedure

Datatype

text

Alias
UMLS CUI [1]
C0543467
Schwangerschaft
Beschrijving

Schwangerschaft

Alias
UMLS CUI-1
C0032961
Schwangerschaft
Beschrijving

Pregnancy

Datatype

boolean

Alias
UMLS CUI [1]
C0032961
akt. Dat
Beschrijving

date

Datatype

date

Alias
UMLS CUI [1]
C0011008
letzte Periode
Beschrijving

Menstruation

Datatype

date

Alias
UMLS CUI [1]
C0025344
akt. Dat - letzte Periode = SSW
Beschrijving

Weeks Pregnant

Datatype

float

Maateenheden
  • Woche
Alias
UMLS CUI [1]
C1135241
Woche
letzte Periode/Dat. = errechnetes Geburtsdatum
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Gravida
Beschrijving

Pregnancy

Datatype

float

Alias
UMLS CUI [1]
C0032961
Para
Beschrijving

Births

Datatype

float

Alias
UMLS CUI [1]
C1148523
Schwangerschaften
Beschrijving

Schwangerschaften

Alias
UMLS CUI-1
C0032961
Jahr
Beschrijving

Year

Datatype

partialDate

Alias
UMLS CUI [1]
C0439234
Modus
Beschrijving

Type Of Birth

Datatype

text

Alias
UMLS CUI [1]
C2239272
Besonderheiten
Beschrijving

Comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Anamnese
Beschrijving

Anamnese

Alias
UMLS CUI-1
C0262926
Größe
Beschrijving

Body height

Datatype

float

Maateenheden
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Gewicht
Beschrijving

body weight

Datatype

float

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

Blood group

Datatype

text

Alias
UMLS CUI [1]
C0005810
Rh
Beschrijving

Rhesus

Datatype

text

Alias
UMLS CUI [1]
C0427641
Nikotin
Beschrijving

Smoking Status

Datatype

boolean

Alias
UMLS CUI [1]
C1519386
Bemerkung
Beschrijving

Comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Alkohol
Beschrijving

Alcohol

Datatype

boolean

Alias
UMLS CUI [1]
C0001948
Bemerkung
Beschrijving

comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Kontrazeption
Beschrijving

Contraceptive Methods

Datatype

text

Alias
UMLS CUI [1]
C0700589
Krebsvorsorge
Beschrijving

Cancer Screening

Datatype

text

Alias
UMLS CUI [1]
C0278974
Mammographie
Beschrijving

Mammography

Datatype

text

Alias
UMLS CUI [1]
C0024671
Allergien
Beschrijving

Allergy

Datatype

boolean

Alias
UMLS CUI [1]
C0020517
Bemerkung
Beschrijving

comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
LP
Beschrijving

Lumbal puncture

Datatype

text

Alias
UMLS CUI [1]
C0553794
Zyklus
Beschrijving

Menstrual cycle

Datatype

text

Alias
UMLS CUI [1]
C0025329
Menopause
Beschrijving

Menopause

Datatype

boolean

Alias
UMLS CUI [1]
C0455962
Seit wann?
Beschrijving

Date Of Beginning Of Menopause

Datatype

date

Alias
UMLS CUI [1]
C0011008
Miktion
Beschrijving

Urination

Datatype

text

Alias
UMLS CUI [1]
C0042034
Stuhlgang
Beschrijving

Defecation

Datatype

text

Alias
UMLS CUI [1]
C0011135
Blutung-/Thromboseneigung
Beschrijving

Bleeding Risk

Datatype

boolean

Alias
UMLS CUI [1]
C3251812
Bemerkung
Beschrijving

comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Körperliche Untersuchung
Beschrijving

Körperliche Untersuchung

Alias
UMLS CUI-1
C0031809
Äußeres Genital
Beschrijving

External Genitalia

Datatype

text

Alias
UMLS CUI [1]
C0227605
Speculum
Beschrijving

Speculum

Datatype

text

Alias
UMLS CUI [1]
C0037816
pH
Beschrijving

pH

Datatype

text

Alias
UMLS CUI [1]
C0042044
Nativ
Beschrijving

Nativ

Datatype

text

Abstrich
Beschrijving

Smear Test

Datatype

boolean

Alias
UMLS CUI [1]
C0444186
Bemerkung
Beschrijving

comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Tastbefund
Beschrijving

Palpation

Datatype

text

Alias
UMLS CUI [1]
C0030247
Sonographie
Beschrijving

Sonographie

Alias
UMLS CUI-1
C0041618
Uterus
Beschrijving

Uterus

Datatype

text

Alias
UMLS CUI [1]
C0042149
Ovar// Adnexe rechts
Beschrijving

Ovary right

Datatype

text

Alias
UMLS CUI [1,1]
C0029939
UMLS CUI [1,2]
C0205090
Ovar// Adnexe links
Beschrijving

Ovary left

Datatype

text

Alias
UMLS CUI [1,1]
C0029939
UMLS CUI [1,2]
C0205091
Douglasraum
Beschrijving

Extracavatio recto

Datatype

text

Alias
UMLS CUI [1]
C0013075
Sono
Beschrijving

Ultrasonography

Datatype

text

Alias
UMLS CUI [1]
C0041618
Mammae
Beschrijving

Breast

Datatype

text

Alias
UMLS CUI [1]
C0006141
sonstiges
Beschrijving

Comment

Datatype

text

Alias
UMLS CUI [1]
C0947611
Diagnosen
Beschrijving

Diagnosen

Alias
UMLS CUI-1
C0011900
Klinische Diagnose
Beschrijving

Diagnosis

Datatype

text

Alias
UMLS CUI [1]
C0011900
Procedere
Beschrijving

Procedere

Alias
UMLS CUI-1
C0087111
Procedere
Beschrijving

Procedure

Datatype

text

Alias
UMLS CUI [1]
C0087111
Unterschriften
Beschrijving

Unterschriften

Alias
UMLS CUI-1
C1519316
Name/Unterschrift des behandelndes Arztes
Beschrijving

Signature Of Attending Physician

Datatype

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C2361125
Name/Unterschrift des behandelnden Facharztes
Beschrijving

Signature Of Treating Physician

Datatype

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C1710470

Similar models

Polyclinic Medical History University Hospital Cologne

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Patientendaten
C2707520 (UMLS CUI-1)
Name
Item
Name:
text
C0027365 (UMLS CUI [1])
Surname
Item
Vorname:
text
C0421448 (UMLS CUI [1])
Date of birth
Item
Geb.-Datum:
date
C0421451 (UMLS CUI [1])
Case number
Item
Fallnummer.:
integer
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Investigator
Item
Anamnese durch
text
C2826892 (UMLS CUI [1])
Item
Vorstellung
integer
C0034927 (UMLS CUI [1])
Code List
Vorstellung
CL Item
Erstvorstellung (1)
CL Item
Wiedervorstellung (2)
Gynecologist
Item
Frauenarzt
text
C0237419 (UMLS CUI [1])
General Practitioners
Item
Hausarzt
text
C0017319 (UMLS CUI [1])
Occupations
Item
Beruf
text
C0028811 (UMLS CUI [1])
Telephone Number
Item
Tel. Pat./ Angehörige
text
C1515258 (UMLS CUI [1])
Telephone Number
Item
Tel. Pat./ Angehörige Mobil:
text
C1515258 (UMLS CUI [1])
Item Group
Vitalzeichen
C0518766 (UMLS CUI-1)
Systolic blood pressure
Item
RR systolisch
float
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
RR diastolisch
float
C0428883 (UMLS CUI [1])
Heart rate
Item
Pulse
float
C0018810 (UMLS CUI [1])
Body temperature
Item
Temp
float
C0886414 (UMLS CUI [1])
hcg
Item
betaHCG
float
C0428402 (UMLS CUI [1])
Item
U-Stix
integer
C0200354 (UMLS CUI [1,1])
C0456984 (UMLS CUI [1,2])
Code List
U-Stix
CL Item
unauffällig (1)
CL Item
auffällig (2)
CL Item
Sonstiges (3)
Specification Of "Other"
Item
Sonstiges
text
C1521902 (UMLS CUI [1])
Item Group
Anamnese
C0262926 (UMLS CUI-1)
Family History
Item
Familienanamnese
boolean
C0241889 (UMLS CUI [1])
Specification
Item
Familienanamnese
text
C0241889 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Comorbidity
Item
Vorerkrankungen
boolean
C0009488 (UMLS CUI [1])
Specification
Item
Vorerkrankungen
text
C0009488 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Item Group
Medikamente (Substanz, Dosierung)
C0013227 (UMLS CUI-1)
Pharmaceutical Preparations
Item
Präparat
text
C0013227 (UMLS CUI [1])
dose
Item
Dosis
text
C3174092 (UMLS CUI [1])
Item Group
Operationen
C0543467 (UMLS CUI-1)
Year
Item
Jahr
partialDate
C0439234 (UMLS CUI [1])
Surgical Procedure
Item
Operation
text
C0543467 (UMLS CUI [1])
Item Group
Schwangerschaft
C0032961 (UMLS CUI-1)
Pregnancy
Item
Schwangerschaft
boolean
C0032961 (UMLS CUI [1])
date
Item
akt. Dat
date
C0011008 (UMLS CUI [1])
Menstruation
Item
letzte Periode
date
C0025344 (UMLS CUI [1])
Weeks Pregnant
Item
akt. Dat - letzte Periode = SSW
float
C1135241 (UMLS CUI [1])
Date of birth
Item
letzte Periode/Dat. = errechnetes Geburtsdatum
date
C0421451 (UMLS CUI [1])
Pregnancy
Item
Gravida
float
C0032961 (UMLS CUI [1])
Births
Item
Para
float
C1148523 (UMLS CUI [1])
Item Group
Schwangerschaften
C0032961 (UMLS CUI-1)
Year
Item
Jahr
partialDate
C0439234 (UMLS CUI [1])
Type Of Birth
Item
Modus
text
C2239272 (UMLS CUI [1])
Comment
Item
Besonderheiten
text
C0947611 (UMLS CUI [1])
Item Group
Anamnese
C0262926 (UMLS CUI-1)
Body height
Item
Größe
float
C0005890 (UMLS CUI [1])
body weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Blood group
Item
Blutgruppe
text
C0005810 (UMLS CUI [1])
Rhesus
Item
Rh
text
C0427641 (UMLS CUI [1])
Smoking Status
Item
Nikotin
boolean
C1519386 (UMLS CUI [1])
Comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Contraceptive Methods
Item
Kontrazeption
text
C0700589 (UMLS CUI [1])
Cancer Screening
Item
Krebsvorsorge
text
C0278974 (UMLS CUI [1])
Mammography
Item
Mammographie
text
C0024671 (UMLS CUI [1])
Allergy
Item
Allergien
boolean
C0020517 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Lumbal puncture
Item
LP
text
C0553794 (UMLS CUI [1])
Menstrual cycle
Item
Zyklus
text
C0025329 (UMLS CUI [1])
Menopause
Item
Menopause
boolean
C0455962 (UMLS CUI [1])
Date Of Beginning Of Menopause
Item
Seit wann?
date
C0011008 (UMLS CUI [1])
Urination
Item
Miktion
text
C0042034 (UMLS CUI [1])
Defecation
Item
Stuhlgang
text
C0011135 (UMLS CUI [1])
Bleeding Risk
Item
Blutung-/Thromboseneigung
boolean
C3251812 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Item Group
Körperliche Untersuchung
C0031809 (UMLS CUI-1)
External Genitalia
Item
Äußeres Genital
text
C0227605 (UMLS CUI [1])
Speculum
Item
Speculum
text
C0037816 (UMLS CUI [1])
pH
Item
pH
text
C0042044 (UMLS CUI [1])
Nativ
Item
Nativ
text
Smear Test
Item
Abstrich
boolean
C0444186 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Palpation
Item
Tastbefund
text
C0030247 (UMLS CUI [1])
Item Group
Sonographie
C0041618 (UMLS CUI-1)
Uterus
Item
Uterus
text
C0042149 (UMLS CUI [1])
Ovary right
Item
Ovar// Adnexe rechts
text
C0029939 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Ovary left
Item
Ovar// Adnexe links
text
C0029939 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Extracavatio recto
Item
Douglasraum
text
C0013075 (UMLS CUI [1])
Ultrasonography
Item
Sono
text
C0041618 (UMLS CUI [1])
Breast
Item
Mammae
text
C0006141 (UMLS CUI [1])
Comment
Item
sonstiges
text
C0947611 (UMLS CUI [1])
Item Group
Diagnosen
C0011900 (UMLS CUI-1)
Diagnosis
Item
Klinische Diagnose
text
C0011900 (UMLS CUI [1])
Item Group
Procedere
C0087111 (UMLS CUI-1)
Procedure
Item
Procedere
text
C0087111 (UMLS CUI [1])
Item Group
Unterschriften
C1519316 (UMLS CUI-1)
Signature Of Attending Physician
Item
Name/Unterschrift des behandelndes Arztes
text
C1519316 (UMLS CUI [1,1])
C2361125 (UMLS CUI [1,2])
Signature Of Treating Physician
Item
Name/Unterschrift des behandelnden Facharztes
text
C1519316 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])

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