ID

21823

Beschreibung

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

Stichworte

  1. 02.05.17 02.05.17 -
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UKM

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2. Mai 2017

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Midwifery medical history Gynaecology UKM

Midwifery medical history

Patient demographics
Beschreibung

Patient demographics

Name
Beschreibung

Name

Datentyp

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Beschreibung

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Address
Beschreibung

Address

Datentyp

text

Alias
UMLS CUI [1]
C0421449
Birth time
Beschreibung

Birth time

Datentyp

time

Alias
UMLS CUI [1]
C2736116
Blood group
Beschreibung

Blood group

Datentyp

integer

Alias
UMLS CUI [1]
C0005810
Health insurance
Beschreibung

Health insurance

Datentyp

integer

Alias
UMLS CUI [1]
C0021682
Address
Beschreibung

Address

Datentyp

text

Alias
UMLS CUI [1]
C0421449
Physician
Beschreibung

Physician

Datentyp

text

Alias
UMLS CUI [1]
C2826892
Age group
Beschreibung

Age group

Datentyp

integer

Alias
UMLS CUI [1]
C0001779
Medication
Beschreibung

Medication

Datentyp

integer

Alias
UMLS CUI [1]
C0013227
Allergies
Beschreibung

Allergies

Datentyp

integer

Alias
UMLS CUI [1]
C0020517
Risk
Beschreibung

Risk

Datentyp

integer

Alias
UMLS CUI [1]
C0035647
Diagnosis
Beschreibung

Diagnosis

Datentyp

integer

Alias
UMLS CUI [1]
C0011900
Therapy
Beschreibung

Therapy

Datentyp

integer

Alias
UMLS CUI [1]
C0087111
Symptoms
Beschreibung

Symptoms

Datentyp

text

Alias
UMLS CUI [1]
C1457887
Medical history
Beschreibung

Medical history

Blood transfusion
Beschreibung

Blood transfusion

Datentyp

boolean

Alias
UMLS CUI [1]
C0005841
Hereditary Diseases
Beschreibung

Hereditary Diseases

Datentyp

boolean

Alias
UMLS CUI [1]
C0019247
Operation
Beschreibung

Operation

Datentyp

boolean

Alias
UMLS CUI [1]
C0543467
Abusus
Beschreibung

Abusus

Datentyp

integer

Alias
UMLS CUI [1]
C0038586
Family history
Beschreibung

Family history

Datentyp

boolean

Alias
UMLS CUI [1]
C0241889
Social and personal history
Beschreibung

Social and personal history

Datentyp

integer

Alias
UMLS CUI [1]
C0424945
Gynecological history
Beschreibung

Gynecological history

Alias
UMLS CUI-1
C0474455
Menarche
Beschreibung

Menarche

Datentyp

integer

Alias
UMLS CUI [1]
C0025274
Menopause
Beschreibung

Menopause

Datentyp

integer

Alias
UMLS CUI [1]
C0025320
Contraception
Beschreibung

Contraception

Datentyp

integer

Alias
UMLS CUI [1]
C0700589
Bleeding disorder
Beschreibung

Bleeding disorder

Datentyp

boolean

Alias
UMLS CUI [1]
C0005779
Gynecological operation
Beschreibung

Gynecological operation

Datentyp

boolean

Alias
UMLS CUI [1]
C0580732
Midwifery history
Beschreibung

Midwifery history

Midwifery
Beschreibung

Midwifery

Datentyp

integer

Alias
UMLS CUI [1]
C0026082
Date of birth
Beschreibung

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Birth weight
Beschreibung

Birth weight

Datentyp

integer

Alias
UMLS CUI [1]
C0005612
Week of gestation
Beschreibung

Week of gestation

Datentyp

integer

Alias
UMLS CUI [1]
C1135241
Delivery
Beschreibung

Delivery

Datentyp

date

Alias
UMLS CUI [1,1]
C1301668
UMLS CUI [1,2]
C2053594
Examination
Beschreibung

Examination

Genital
Beschreibung

Genital

Datentyp

integer

Alias
UMLS CUI [1]
C0017420
Vagina
Beschreibung

Vagina

Datentyp

integer

Alias
UMLS CUI [1]
C0042232
Cervix
Beschreibung

Cervix

Datentyp

integer

Alias
UMLS CUI [1]
C0007874
Uterus
Beschreibung

Uterus

Datentyp

integer

Alias
UMLS CUI [1]
C0007874
Uterine adnexae structure
Beschreibung

Uterine adnexae structure

Datentyp

integer

Alias
UMLS CUI [1]
C0001575
Rectum
Beschreibung

Rectum

Datentyp

integer

Alias
UMLS CUI [1]
C0001575
Mamma
Beschreibung

Mamma

Datentyp

integer

Alias
UMLS CUI [1]
C1268990
Skin
Beschreibung

Skin

Datentyp

integer

Alias
UMLS CUI [1]
C1268990
Head
Beschreibung

Head

Datentyp

integer

Alias
UMLS CUI [1]
C1268990
Chest
Beschreibung

Chest

Datentyp

integer

Alias
UMLS CUI [1]
C0817096
Heart
Beschreibung

Heart

Datentyp

integer

Alias
UMLS CUI [1]
C0018787
Lungs
Beschreibung

Lungs

Datentyp

integer

Alias
UMLS CUI [1]
C2228454
Abdomen
Beschreibung

Abdomen

Datentyp

integer

Alias
UMLS CUI [1]
C0000726
Kindey
Beschreibung

Kidney

Datentyp

integer

Alias
UMLS CUI [1]
C0022646
Limbs
Beschreibung

Limbs

Datentyp

integer

Alias
UMLS CUI [1]
C0015385
Nerv
Beschreibung

Nerv

Datentyp

integer

Alias
UMLS CUI [1]
C0027763
Pap smear
Beschreibung

Pap smear

Datentyp

integer

Alias
UMLS CUI [1]
C0079104
Speculum
Beschreibung

Speculum

Datentyp

integer

Alias
UMLS CUI [1]
C0037816
Palpation
Beschreibung

Palpation

Datentyp

integer

Alias
UMLS CUI [1]
C0030247
Cerclage
Beschreibung

Cerclage

Datentyp

integer

Alias
UMLS CUI [1]
C1292825
Procedure
Beschreibung

Procedure

Alias
UMLS CUI-1
C2700391
Admission
Beschreibung

Admission

Datentyp

integer

Alias
UMLS CUI [1]
C0030673
Gynecologist transfer
Beschreibung

Gynecologist transfer

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0237419
UMLS CUI [1,2]
C0030704
Weeks pregnant
Beschreibung

Weeks pregnant

Datentyp

integer

Alias
UMLS CUI [1]
C1135241
Laboratory test finding
Beschreibung

Laboratory test finding

Datentyp

text

Alias
UMLS CUI [1]
C0587081
Blood group
Beschreibung

Blood group

Datentyp

integer

Alias
UMLS CUI [1]
C0005810
CTG
Beschreibung

CTG

Datentyp

boolean

Alias
UMLS CUI [1]
C0007208
Temperature
Beschreibung

Temperature

Datentyp

integer

Alias
UMLS CUI [1]
C0039476
Blood sugar
Beschreibung

Blood sugar

Datentyp

integer

Maßeinheiten
  • mg%
Alias
UMLS CUI [1]
C0392201
Thromboembolic deterrent stockings
Beschreibung

Thromboembolic deterrent stockings

Datentyp

boolean

Alias
UMLS CUI [1]
C0038348
Heparin, Low-Molecular-Weight
Beschreibung

Heparin, Low-Molecular-Weight

Datentyp

boolean

Alias
UMLS CUI [1]
C0019139
Neonatal respiratory distress syndrome prophylaxis
Beschreibung

Neonatal respiratory distress syndrome prophylaxis

Datentyp

boolean

Alias
UMLS CUI [1]
C1096326
paediatric clinic
Beschreibung

paediatric clinic

Datentyp

boolean

Alias
UMLS CUI [1]
C3839701
Sectio consent obtained
Beschreibung

Sectio consent obtained

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0007876
UMLS CUI [1,2]
C0514044
Premedication
Beschreibung

Premedication

Datentyp

boolean

Alias
UMLS CUI [1]
C0033045
Footer module
Beschreibung

Footer module

Date
Beschreibung

Date

Datentyp

date

Alias
UMLS CUI [1]
C0011008
Signature
Beschreibung

Signature

Datentyp

text

Alias
UMLS CUI [1]
C1519316

Ähnliche Modelle

Midwifery medical history

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Patient demographics
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Birth time
Item
Birth time
time
C2736116 (UMLS CUI [1])
Blood group
Item
Blood group
integer
C0005810 (UMLS CUI [1])
Health insurance
Item
Health insurance
integer
C0021682 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Physician
Item
Physician
text
C2826892 (UMLS CUI [1])
Age group
Item
Age group
integer
C0001779 (UMLS CUI [1])
Medication
Item
Medication
integer
C0013227 (UMLS CUI [1])
Allergies
Item
Allergies
integer
C0020517 (UMLS CUI [1])
Risk
Item
Risk
integer
C0035647 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Therapy
Item
Therapy
integer
C0087111 (UMLS CUI [1])
Symptoms
Item
Symptoms
text
C1457887 (UMLS CUI [1])
Item Group
Medical history
Blood transfusion
Item
Blood transfusion
boolean
C0005841 (UMLS CUI [1])
Hereditary Diseases
Item
Hereditary Diseases
boolean
C0019247 (UMLS CUI [1])
Operation
Item
Operation
boolean
C0543467 (UMLS CUI [1])
Abusus
Item
Abusus
integer
C0038586 (UMLS CUI [1])
Family history
Item
Family history
boolean
C0241889 (UMLS CUI [1])
Item
Social and personal history
integer
C0424945 (UMLS CUI [1])
Code List
Social and personal history
CL Item
country of origin (1)
C3262211 (UMLS CUI-1)
CL Item
single (2)
C0037179 (UMLS CUI-1)
CL Item
married (3)
C0555047 (UMLS CUI-1)
CL Item
Occupation (4)
C0028811 (UMLS CUI-1)
CL Item
relatives (5)
C0080103 (UMLS CUI-1)
Item Group
Gynecological history
C0474455 (UMLS CUI-1)
Menarche
Item
Menarche
integer
C0025274 (UMLS CUI [1])
Menopause
Item
Menopause
integer
C0025320 (UMLS CUI [1])
Contraception
Item
Contraception
integer
C0700589 (UMLS CUI [1])
Bleeding disorder
Item
Bleeding disorder
boolean
C0005779 (UMLS CUI [1])
Gynecological operation
Item
Gynecological operation
boolean
C0580732 (UMLS CUI [1])
Item Group
Midwifery history
Midwifery
Item
Midwifery
integer
C0026082 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Birth weight
Item
Birth weight
integer
C0005612 (UMLS CUI [1])
Week of gestation
Item
Week of gestation
integer
C1135241 (UMLS CUI [1])
Delivery
Item
Delivery
date
C1301668 (UMLS CUI [1,1])
C2053594 (UMLS CUI [1,2])
Item Group
Examination
Item
Genital
integer
C0017420 (UMLS CUI [1])
Code List
Genital
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Vagina
integer
C0042232 (UMLS CUI [1])
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])
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])
Code List
Uterus
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Uterine adnexae structure
integer
C0001575 (UMLS CUI [1])
Code List
Uterine adnexae structure
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Rectum
integer
C0001575 (UMLS CUI [1])
Code List
Rectum
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Mamma
integer
C1268990 (UMLS CUI [1])
Code List
Mamma
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Skin
integer
C1268990 (UMLS CUI [1])
Code List
Skin
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Head
integer
C1268990 (UMLS CUI [1])
Code List
Head
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Chest
integer
C0817096 (UMLS CUI [1])
Code List
Chest
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Heart
integer
C0018787 (UMLS CUI [1])
Code List
Heart
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Lungs
integer
C2228454 (UMLS CUI [1])
Code List
Lungs
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Abdomen
integer
C0000726 (UMLS CUI [1])
Code List
Abdomen
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Kindey
integer
C0022646 (UMLS CUI [1])
Code List
Kindey
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Limbs
integer
C0015385 (UMLS CUI [1])
Code List
Limbs
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Nerv
integer
C0027763 (UMLS CUI [1])
Code List
Nerv
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Pap smear
Item
Pap smear
integer
C0079104 (UMLS CUI [1])
Item
Speculum
integer
C0037816 (UMLS CUI [1])
Code List
Speculum
CL Item
Bacteriology (1)
C0004644 (UMLS CUI-1)
CL Item
Nickerson (2)
CL Item
Chlamydia (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])
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
Procedure
C2700391 (UMLS CUI-1)
Item
Admission
integer
C0030673 (UMLS CUI [1])
Code List
Admission
CL Item
inpatient (1)
CL Item
outpatient (2)
Gynecologist transfer
Item
Gynecologist transfer
boolean
C0237419 (UMLS CUI [1,1])
C0030704 (UMLS CUI [1,2])
Weeks pregnant
Item
Weeks pregnant
integer
C1135241 (UMLS CUI [1])
Laboratory test finding
Item
Laboratory test finding
text
C0587081 (UMLS CUI [1])
Blood group
Item
Blood group
integer
C0005810 (UMLS CUI [1])
CTG
Item
CTG
boolean
C0007208 (UMLS CUI [1])
Temperature
Item
Temperature
integer
C0039476 (UMLS CUI [1])
Item
Blood sugar
integer
C0392201 (UMLS CUI [1])
Code List
Blood sugar
CL Item
OGTT (1)
Thromboembolic deterrent stockings
Item
Thromboembolic deterrent stockings
boolean
C0038348 (UMLS CUI [1])
Heparin, Low-Molecular-Weight
Item
Heparin, Low-Molecular-Weight
boolean
C0019139 (UMLS CUI [1])
Neonatal respiratory distress syndrome prophylaxis
Item
Neonatal respiratory distress syndrome prophylaxis
boolean
C1096326 (UMLS CUI [1])
paediatric clinic
Item
paediatric clinic
boolean
C3839701 (UMLS CUI [1])
Sectio consent obtained
Item
Sectio consent obtained
boolean
C0007876 (UMLS CUI [1,1])
C0514044 (UMLS CUI [1,2])
Premedication
Item
Premedication
boolean
C0033045 (UMLS CUI [1])
Item Group
Footer module
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])

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