ID

21864

Beschrijving

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: Untersuchung_Neuro

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  1. 04-05-17 04-05-17 -
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4 mei 2017

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Neurologic examination, University Hospital Cologne

Duits

Neurologic examination, University Hospital Cologne

1 Formulieren  
Untersuchungsbogen der Neurologie
Beschrijving

Untersuchungsbogen der Neurologie

Alias
UMLS CUI-1
C0027853
Patient
Beschrijving

Patient name

Datatype

text

Alias
UMLS CUI [1]
C1299487
Geburtsdatum
Beschrijving

Birth Date

Datatype

date

Maateenheden
  • dd.mm.yyyy
Alias
UMLS CUI [1]
C0421451
dd.mm.yyyy
Fachabteilung
Beschrijving

Medical specialty

Datatype

text

Alias
UMLS CUI [1]
C0037778
Station
Beschrijving

Ward

Datatype

text

Alias
UMLS CUI [1]
C1305702
Syndrom
Beschrijving

Syndrome

Datatype

text

Alias
UMLS CUI [1]
C0039082
Diagnose(n)
Beschrijving

Diagnosis

Datatype

text

Alias
UMLS CUI [1]
C0011900
Differentialdiagnose(n)
Beschrijving

Differential diagnosis

Datatype

text

Alias
UMLS CUI [1]
C0011906
Aktuelle Anamnese
Beschrijving

Current history

Datatype

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0521116
Vorgeschichte
Beschrijving

Medical history

Datatype

text

Alias
UMLS CUI [1]
C0262926
Medikation bei Aufnahme
Beschrijving

Medication on admission

Datatype

text

Alias
UMLS CUI [1,1]
C1553892
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0457453
Dokumentiert von
Beschrijving

Documented by

Datatype

text

Maateenheden
  • Name und Funktion
Alias
UMLS CUI [1]
C2361125
Name und Funktion
Dokumentiert am
Beschrijving

Date of documentation

Datatype

date

Maateenheden
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0920316
dd.mm.yyyy
Vegetative Anamnese
Beschrijving

Vegetative Anamnese

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0004388
Stuhlgang
Beschrijving

Defecation

Datatype

text

Alias
UMLS CUI [1]
C0011135
Wasserlassen
Beschrijving

Urination

Datatype

text

Alias
UMLS CUI [1]
C0042034
Schlaf
Beschrijving

Sleep

Datatype

text

Alias
UMLS CUI [1]
C0037313
Appetit
Beschrijving

Appetite

Datatype

text

Alias
UMLS CUI [1]
C0003618
Gewicht
Beschrijving

Body weight changes

Datatype

text

Alias
UMLS CUI [1]
C0005911
Allergien
Beschrijving

Allergies

Datatype

text

Alias
UMLS CUI [1]
C0020517
Nikotin
Beschrijving

Tobacco use

Datatype

integer

Maateenheden
  • Zig./Tag
Alias
UMLS CUI [1]
C0543414
Zig./Tag
Alkoholkonsum
Beschrijving

Alcohol consumption

Datatype

text

Alias
UMLS CUI [1]
C0001948
Sozial- und Familienanamnese
Beschrijving

Sozial- und Familienanamnese

Alias
UMLS CUI-1
C3714536
UMLS CUI-2
C0241889
Sozialanamnese
Beschrijving

Social history

Datatype

text

Alias
UMLS CUI [1]
C3714536
Familienanamnese
Beschrijving

Family history

Datatype

text

Alias
UMLS CUI [1]
C0241889
Klinischer Untersuchungsbefund
Beschrijving

Klinischer Untersuchungsbefund

Alias
UMLS CUI-1
C0438105
UMLS CUI-2
C0031809
Neurologischer Untersuchungsbefund (Freitext)
Beschrijving

Neurologic examination finding

Datatype

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0243095
Kopf
Beschrijving

Head

Datatype

integer

Alias
UMLS CUI [1]
C0018670
Hirnnerven I-VII
Beschrijving

Cranial nerves I-VII

Datatype

integer

Alias
UMLS CUI [1]
C0010268
Hirnnerven VIII-XII
Beschrijving

Cranial nerves VIII-XII

Datatype

integer

Alias
UMLS CUI [1]
C0010268
Reflexe
Beschrijving

Reflexes

Datatype

integer

Alias
UMLS CUI [1]
C0436145
Spastik
Beschrijving

Spasticity

Datatype

integer

Alias
UMLS CUI [1]
C0026838
Motorik
Beschrijving

Motor function

Datatype

integer

Alias
UMLS CUI [1]
C0234130
Koordination, Gang, Stand
Beschrijving

Coordination, gait, ability to stand

Datatype

integer

Alias
UMLS CUI [1]
C0242414
UMLS CUI [2]
C0016928
UMLS CUI [3]
C0560788
Trophik: endokrines/vegetatives System
Beschrijving

Endocrine finding, vegetative system finding

Datatype

integer

Alias
UMLS CUI [1]
C0559306
UMLS CUI [2]
C0004388
Orientierende internistische Untersuchung
Beschrijving

Internistic finding

Datatype

integer

Alias
UMLS CUI [1,1]
C0199209
UMLS CUI [1,2]
C0278602
Psychopathologie/Neuropsychologie
Beschrijving

Psychopathologic/neuropsychologic finding

Datatype

integer

Alias
UMLS CUI [1,1]
C0033927
UMLS CUI [1,2]
C0243095
UMLS CUI [2,1]
C0027903
UMLS CUI [2,2]
C0243095
Muskelstatus Kraftgrad
Beschrijving

Motor strength examination

Datatype

integer

Alias
UMLS CUI [1]
C2228462
Sensibilität intakt
Beschrijving

Sensibility

Datatype

boolean

Alias
UMLS CUI [1]
C0439823
Berührung/Schmerz intakt
Beschrijving

Touch sensation, pain sensation

Datatype

boolean

Alias
UMLS CUI [1]
C0576659
UMLS CUI [2]
C0558828
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Similar models

Neurologic examination, University Hospital Cologne

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Untersuchungsbogen der Neurologie
C0027853 (UMLS CUI-1)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Medical specialty
Item
Fachabteilung
text
C0037778 (UMLS CUI [1])
Ward
Item
Station
text
C1305702 (UMLS CUI [1])
Syndrome
Item
Syndrom
text
C0039082 (UMLS CUI [1])
Diagnosis
Item
Diagnose(n)
text
C0011900 (UMLS CUI [1])
Differential diagnosis
Item
Differentialdiagnose(n)
text
C0011906 (UMLS CUI [1])
Current history
Item
Aktuelle Anamnese
text
C0262926 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Medical history
Item
Vorgeschichte
text
C0262926 (UMLS CUI [1])
Medication on admission
Item
Medikation bei Aufnahme
text
C1553892 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0457453 (UMLS CUI [1,3])
Documented by
Item
Dokumentiert von
text
C2361125 (UMLS CUI [1])
Date of documentation
Item
Dokumentiert am
date
C0011008 (UMLS CUI [1,1])
C0920316 (UMLS CUI [1,2])
Item Group
Vegetative Anamnese
C0262926 (UMLS CUI-1)
C0004388 (UMLS CUI-2)
Defecation
Item
Stuhlgang
text
C0011135 (UMLS CUI [1])
Urination
Item
Wasserlassen
text
C0042034 (UMLS CUI [1])
Sleep
Item
Schlaf
text
C0037313 (UMLS CUI [1])
Appetite
Item
Appetit
text
C0003618 (UMLS CUI [1])
Body weight changes
Item
Gewicht
text
C0005911 (UMLS CUI [1])
Allergies
Item
Allergien
text
C0020517 (UMLS CUI [1])
Tobacco use
Item
Nikotin
integer
C0543414 (UMLS CUI [1])
Alcohol consumption
Item
Alkoholkonsum
text
C0001948 (UMLS CUI [1])
Item Group
Sozial- und Familienanamnese
C3714536 (UMLS CUI-1)
C0241889 (UMLS CUI-2)
Social history
Item
Sozialanamnese
text
C3714536 (UMLS CUI [1])
Family history
Item
Familienanamnese
text
C0241889 (UMLS CUI [1])
Item Group
Klinischer Untersuchungsbefund
C0438105 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
Neurologic examination finding
Item
Neurologischer Untersuchungsbefund (Freitext)
text
C0027853 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Item
Kopf
integer
C0018670 (UMLS CUI [1])
Head
Code List
Kopf
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Hirnnerven I-VII
integer
C0010268 (UMLS CUI [1])
Cranial nerves I-VII
Code List
Hirnnerven I-VII
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Hirnnerven VIII-XII
integer
C0010268 (UMLS CUI [1])
Cranial nerves VIII-XII
Code List
Hirnnerven VIII-XII
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Reflexe
integer
C0436145 (UMLS CUI [1])
Reflexes
Code List
Reflexe
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Spastik
integer
C0026838 (UMLS CUI [1])
Spasticity
Code List
Spastik
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Motorik
integer
C0234130 (UMLS CUI [1])
Motor function
Code List
Motorik
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Koordination, Gang, Stand
integer
C0242414 (UMLS CUI [1])
C0016928 (UMLS CUI [2])
C0560788 (UMLS CUI [3])
Coordination, gait, ability to stand
Code List
Koordination, Gang, Stand
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Trophik: endokrines/vegetatives System
integer
C0559306 (UMLS CUI [1])
C0004388 (UMLS CUI [2])
Endocrine finding, vegetative system finding
Code List
Trophik: endokrines/vegetatives System
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Orientierende internistische Untersuchung
integer
C0199209 (UMLS CUI [1,1])
C0278602 (UMLS CUI [1,2])
Internistic finding
Code List
Orientierende internistische Untersuchung
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Psychopathologie/Neuropsychologie
integer
C0033927 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0027903 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
Psychopathologic/neuropsychologic finding
Code List
Psychopathologie/Neuropsychologie
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Muskelstatus Kraftgrad
integer
C2228462 (UMLS CUI [1])
Strength examination
Code List
Muskelstatus Kraftgrad
CL Item
5 (1)
CL Item
4 (2)
CL Item
3 (3)
CL Item
2 (4)
CL Item
1 (5)
CL Item
0 (6)
Sensibility
Item
Sensibilität intakt
boolean
C0439823 (UMLS CUI [1])
Touch sensation, pain sensation
Item
Berührung/Schmerz intakt
boolean
C0576659 (UMLS CUI [1])
C0558828 (UMLS CUI [2])
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