ID

21823

Description

Midwifery medical history form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Prof. Dr. med. Ludwig Kiesel

Keywords

Versions (1)
  1. 5/2/17 5/2/17 -
Copyright Holder

UKM

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May 2, 2017

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Creative Commons BY-NC 3.0
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Midwifery medical history Gynaecology UKM

German English

Midwifery medical history

1 forms  
Patientendaten
Description

Patientendaten

Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Addresse
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Geb.-Zeit
Description

Birth time

Data type

time

Alias
UMLS CUI [1]
C2736116
Blutgruppe der Mutter
Description

Blood group

Data type

integer

Alias
UMLS CUI [1]
C0005810
Antikörper
Description

Health insurance

Data type

integer

Alias
UMLS CUI [1]
C0021682
Hebamme
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Arzt
Description

Physician

Data type

text

Alias
UMLS CUI [1]
C2826892
Jahrgang
Description

Age group

Data type

integer

Alias
UMLS CUI [1]
C0001779
Dauermed.:
Description

Medication

Data type

integer

Alias
UMLS CUI [1]
C0013227
Allergien:
Description

Allergies

Data type

integer

Alias
UMLS CUI [1]
C0020517
Risiken:
Description

Risk

Data type

integer

Alias
UMLS CUI [1]
C0035647
Diagnose
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Therapie
Description

Therapy

Data type

integer

Alias
UMLS CUI [1]
C0087111
Aktuelle Beschwerden
Description

Symptoms

Data type

text

Alias
UMLS CUI [1]
C1457887
Untersuchung
Description

Untersuchung

Bluttransfusionen
Description

Blood transfusion

Data type

boolean

Alias
UMLS CUI [1]
C0005841
Erbleiden
Description

Hereditary Diseases

Data type

boolean

Alias
UMLS CUI [1]
C0019247
Operationen
Description

Operation

Data type

boolean

Alias
UMLS CUI [1]
C0543467
Abusus
Description

Abusus

Data type

integer

Alias
UMLS CUI [1]
C0038586
Familienanamnese
Description

Family history

Data type

boolean

Alias
UMLS CUI [1]
C0241889
Sozialanamnese
Description

Social and personal history

Data type

integer

Alias
UMLS CUI [1]
C0424945
gynäkologische Anamnese
Description

gynäkologische Anamnese

Alias
UMLS CUI-1
C0474455
Menarche:
Description

Menarche

Data type

integer

Alias
UMLS CUI [1]
C0025274
Menopause:
Description

Menopause

Data type

integer

Alias
UMLS CUI [1]
C0025320
Antikonzeption:
Description

Contraception

Data type

integer

Alias
UMLS CUI [1]
C0700589
Blutungsstörungen:
Description

Bleeding disorder

Data type

boolean

Alias
UMLS CUI [1]
C0005779
gyn. Operationen:
Description

Gynecological operation

Data type

boolean

Alias
UMLS CUI [1]
C0580732
geburtshilfliche Anamnese
Description

geburtshilfliche Anamnese

Geburtshilfe
Description

Midwifery

Data type

integer

Alias
UMLS CUI [1]
C0026082
Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Geburtsgewicht
Description

Birth weight

Data type

integer

Alias
UMLS CUI [1]
C0005612
Grav-Woch.
Description

Week of gestation

Data type

integer

Alias
UMLS CUI [1]
C1135241
Entbindung
Description

Delivery

Data type

date

Alias
UMLS CUI [1,1]
C1301668
UMLS CUI [1,2]
C2053594
Erstuntersuchung
Description

Erstuntersuchung

äuß. Gen.
Description

Genital

Data type

integer

Alias
UMLS CUI [1]
C0017420
Vagina
Description

Vagina

Data type

integer

Alias
UMLS CUI [1]
C0042232
Cervix
Description

Cervix

Data type

integer

Alias
UMLS CUI [1]
C0007874
Uterus
Description

Uterus

Data type

integer

Alias
UMLS CUI [1]
C0007874
Adnexe
Description

Uterine adnexae structure

Data type

integer

Alias
UMLS CUI [1]
C0001575
Rektum
Description

Rectum

Data type

integer

Alias
UMLS CUI [1]
C0001575
Mamma
Description

Mamma

Data type

integer

Alias
UMLS CUI [1]
C1268990
Haut
Description

Skin

Data type

integer

Alias
UMLS CUI [1]
C1268990
Kopf
Description

Head

Data type

integer

Alias
UMLS CUI [1]
C1268990
Thorax
Description

Chest

Data type

integer

Alias
UMLS CUI [1]
C0817096
Herz
Description

Heart

Data type

integer

Alias
UMLS CUI [1]
C0018787
Lunge
Description

Lungs

Data type

integer

Alias
UMLS CUI [1]
C2228454
Abdomen
Description

Abdomen

Data type

integer

Alias
UMLS CUI [1]
C0000726
Nieren
Description

Kidney

Data type

integer

Alias
UMLS CUI [1]
C0022646
Extrem.
Description

Limbs

Data type

integer

Alias
UMLS CUI [1]
C0015385
Nerven
Description

Nerv

Data type

integer

Alias
UMLS CUI [1]
C0027763
PAP
Description

Pap smear

Data type

integer

Alias
UMLS CUI [1]
C0079104
Speculum
Description

Speculum

Data type

integer

Alias
UMLS CUI [1]
C0037816
Palpation
Description

Palpation

Data type

integer

Alias
UMLS CUI [1]
C0030247
Cerclage
Description

Cerclage

Data type

integer

Alias
UMLS CUI [1]
C1292825
PROCEDERE
Description

PROCEDERE

Alias
UMLS CUI-1
C2700391
Aufnahme
Description

Admission

Data type

integer

Alias
UMLS CUI [1]
C0030673
Frauenarzt
Description

Gynecologist transfer

Data type

boolean

Alias
UMLS CUI [1,1]
C0237419
UMLS CUI [1,2]
C0030704
SSW
Description

Weeks pregnant

Data type

integer

Alias
UMLS CUI [1]
C1135241
Gesamtlabor
Description

Laboratory test finding

Data type

text

Alias
UMLS CUI [1]
C0587081
Blutgruppe
Description

Blood group

Data type

integer

Alias
UMLS CUI [1]
C0005810
CTG
Description

CTG

Data type

boolean

Alias
UMLS CUI [1]
C0007208
Temperatur
Description

Temperature

Data type

integer

Alias
UMLS CUI [1]
C0039476
OGTT
Description

Blood sugar

Data type

integer

Measurement units
  • mg%
Alias
UMLS CUI [1]
C0392201
Antithrombosestrümpfe
Description

Thromboembolic deterrent stockings

Data type

boolean

Alias
UMLS CUI [1]
C0038348
niedermolekulares Heparin
Description

Heparin, Low-Molecular-Weight

Data type

boolean

Alias
UMLS CUI [1]
C0019139
RDS-Prophylaxe
Description

Neonatal respiratory distress syndrome prophylaxis

Data type

boolean

Alias
UMLS CUI [1]
C1096326
Kinderklinik
Description

paediatric clinic

Data type

boolean

Alias
UMLS CUI [1]
C3839701
Sectioaufklärung
Description

Sectio consent obtained

Data type

boolean

Alias
UMLS CUI [1,1]
C0007876
UMLS CUI [1,2]
C0514044
Prämedikation
Description

Premedication

Data type

boolean

Alias
UMLS CUI [1]
C0033045
Unterschrift
Description

Unterschrift

Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Unterschrift
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Midwifery medical history

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patientendaten
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Address
Item
Addresse
text
C0421449 (UMLS CUI [1])
Birth time
Item
Geb.-Zeit
time
C2736116 (UMLS CUI [1])
Blood group
Item
Blutgruppe der Mutter
integer
C0005810 (UMLS CUI [1])
Health insurance
Item
Antikörper
integer
C0021682 (UMLS CUI [1])
Address
Item
Hebamme
text
C0421449 (UMLS CUI [1])
Physician
Item
Arzt
text
C2826892 (UMLS CUI [1])
Age group
Item
Jahrgang
integer
C0001779 (UMLS CUI [1])
Medication
Item
Dauermed.:
integer
C0013227 (UMLS CUI [1])
Allergies
Item
Allergien:
integer
C0020517 (UMLS CUI [1])
Risk
Item
Risiken:
integer
C0035647 (UMLS CUI [1])
Diagnosis
Item
Diagnose
integer
C0011900 (UMLS CUI [1])
Therapy
Item
Therapie
integer
C0087111 (UMLS CUI [1])
Symptoms
Item
Aktuelle Beschwerden
text
C1457887 (UMLS CUI [1])
Item Group
Untersuchung
Blood transfusion
Item
Bluttransfusionen
boolean
C0005841 (UMLS CUI [1])
Hereditary Diseases
Item
Erbleiden
boolean
C0019247 (UMLS CUI [1])
Operation
Item
Operationen
boolean
C0543467 (UMLS CUI [1])
Abusus
Item
Abusus
integer
C0038586 (UMLS CUI [1])
Family history
Item
Familienanamnese
boolean
C0241889 (UMLS CUI [1])
Item
Sozialanamnese
integer
C0424945 (UMLS CUI [1])
Social and personal history
Code List
Sozialanamnese
CL Item
Herkunftsland (1)
C3262211 (UMLS CUI-1)
CL Item
allein stehend (2)
C0037179 (UMLS CUI-1)
CL Item
verheiratet (3)
C0555047 (UMLS CUI-1)
CL Item
Beruf (4)
C0028811 (UMLS CUI-1)
CL Item
Angehörige (5)
C0080103 (UMLS CUI-1)
Item Group
gynäkologische Anamnese
C0474455 (UMLS CUI-1)
Menarche
Item
Menarche:
integer
C0025274 (UMLS CUI [1])
Menopause
Item
Menopause:
integer
C0025320 (UMLS CUI [1])
Contraception
Item
Antikonzeption:
integer
C0700589 (UMLS CUI [1])
Bleeding disorder
Item
Blutungsstörungen:
boolean
C0005779 (UMLS CUI [1])
Gynecological operation
Item
gyn. Operationen:
boolean
C0580732 (UMLS CUI [1])
Item Group
geburtshilfliche Anamnese
Midwifery
Item
Geburtshilfe
integer
C0026082 (UMLS CUI [1])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Birth weight
Item
Geburtsgewicht
integer
C0005612 (UMLS CUI [1])
Week of gestation
Item
Grav-Woch.
integer
C1135241 (UMLS CUI [1])
Delivery
Item
Entbindung
date
C1301668 (UMLS CUI [1,1])
C2053594 (UMLS CUI [1,2])
Item Group
Erstuntersuchung
Item
äuß. Gen.
integer
C0017420 (UMLS CUI [1])
Genital
Code List
äuß. Gen.
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Vagina
integer
C0042232 (UMLS CUI [1])
Genital
Code List
Vagina
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Cervix
integer
C0007874 (UMLS CUI [1])
Genital
Code List
Cervix
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Uterus
integer
C0007874 (UMLS CUI [1])
Genital
Code List
Uterus
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Adnexe
integer
C0001575 (UMLS CUI [1])
Genital
Code List
Adnexe
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Rektum
integer
C0001575 (UMLS CUI [1])
Genital
Code List
Rektum
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Mamma
integer
C1268990 (UMLS CUI [1])
Genital
Code List
Mamma
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Haut
integer
C1268990 (UMLS CUI [1])
Genital
Code List
Haut
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Kopf
integer
C1268990 (UMLS CUI [1])
Genital
Code List
Kopf
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Thorax
integer
C0817096 (UMLS CUI [1])
Genital
Code List
Thorax
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Herz
integer
C0018787 (UMLS CUI [1])
Genital
Code List
Herz
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Lunge
integer
C2228454 (UMLS CUI [1])
Genital
Code List
Lunge
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Abdomen
integer
C0000726 (UMLS CUI [1])
Genital
Code List
Abdomen
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Nieren
integer
C0022646 (UMLS CUI [1])
Genital
Code List
Nieren
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Extrem.
integer
C0015385 (UMLS CUI [1])
Genital
Code List
Extrem.
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Nerven
integer
C0027763 (UMLS CUI [1])
Genital
Code List
Nerven
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Pap smear
Item
PAP
integer
C0079104 (UMLS CUI [1])
Item
Speculum
integer
C0037816 (UMLS CUI [1])
Speculum
Code List
Speculum
CL Item
Bakteriologie (1)
C0004644 (UMLS CUI-1)
CL Item
Nickerson (2)
CL Item
Chlamydien (3)
C0008148 (UMLS CUI-1)
CL Item
Urethra (4)
C0041967 (UMLS CUI-1)
CL Item
PAP (5)
C0199629 (UMLS CUI-1)
Item
Palpation
integer
C0030247 (UMLS CUI [1])
Palpation
Code List
Palpation
CL Item
Promontorium (1)
C1405507 (UMLS CUI-1)
CL Item
Conjugata diagonalis (2)
C0923004 (UMLS CUI-1)
CL Item
Os pubis (3)
C0034014 (UMLS CUI-1)
Cerclage
Item
Cerclage
integer
C1292825 (UMLS CUI [1])
Item Group
PROCEDERE
C2700391 (UMLS CUI-1)
Item
Aufnahme
integer
C0030673 (UMLS CUI [1])
Admission
Code List
Aufnahme
CL Item
stationäre Aufnahme (1)
CL Item
ambulante Vorstellung (2)
Gynecologist transfer
Item
Frauenarzt
boolean
C0237419 (UMLS CUI [1,1])
C0030704 (UMLS CUI [1,2])
Weeks pregnant
Item
SSW
integer
C1135241 (UMLS CUI [1])
Laboratory test finding
Item
Gesamtlabor
text
C0587081 (UMLS CUI [1])
Blood group
Item
Blutgruppe
integer
C0005810 (UMLS CUI [1])
CTG
Item
CTG
boolean
C0007208 (UMLS CUI [1])
Temperature
Item
Temperatur
integer
C0039476 (UMLS CUI [1])
Item
OGTT
integer
C0392201 (UMLS CUI [1])
Blood sugar
Code List
OGTT
CL Item
OGTT (1)
Thromboembolic deterrent stockings
Item
Antithrombosestrümpfe
boolean
C0038348 (UMLS CUI [1])
Heparin, Low-Molecular-Weight
Item
niedermolekulares Heparin
boolean
C0019139 (UMLS CUI [1])
Neonatal respiratory distress syndrome prophylaxis
Item
RDS-Prophylaxe
boolean
C1096326 (UMLS CUI [1])
paediatric clinic
Item
Kinderklinik
boolean
C3839701 (UMLS CUI [1])
Sectio consent obtained
Item
Sectioaufklärung
boolean
C0007876 (UMLS CUI [1,1])
C0514044 (UMLS CUI [1,2])
Premedication
Item
Prämedikation
boolean
C0033045 (UMLS CUI [1])
Item Group
Unterschrift
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
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