ID

21967

Description

General 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. 5/10/17 5/10/17 -
Copyright Holder

UKM

Uploaded on

May 10, 2017

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License

Creative Commons BY-NC 3.0
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General medical history Gynaecology UKM

German English

General 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
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
Risiken:
Description

Risk

Data type

integer

Alias
UMLS CUI [1]
C0035647
Geburtshilfliche Anamnese
Description

Geburtshilfliche Anamnese

Alias
UMLS CUI-1
C1148523
Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Geb.-Datum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Para
Description

Gravidity and parity

Data type

integer

Alias
UMLS CUI [1]
C0030563
Entbindungsdatum
Description

Date of delivery

Data type

date

Alias
UMLS CUI [1]
C2053594
Geburtszeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Hebamme
Description

Midwife

Data type

integer

Alias
UMLS CUI [1]
C0026083
Arzt
Description

Physician

Data type

integer

Alias
UMLS CUI [1]
C2826892
Medical history
Description

Medical history

Allergien:
Description

Allergies

Data type

integer

Alias
UMLS CUI [1]
C0020517
Dauermed.:
Description

Medication

Data type

integer

Alias
UMLS CUI [1]
C0013227
Aktuelle Beschwerden:
Description

Symptoms

Data type

text

Alias
UMLS CUI [1]
C1457887
Verlauf
Description

Clinical course

Data type

text

Alias
UMLS CUI [1]
C0449259
Diagnose
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Diagnose
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Therapie
Description

Therapy

Data type

integer

Alias
UMLS CUI [1]
C0087111
Para
Description

Parity

Data type

integer

Alias
UMLS CUI [1]
C0030563
Operationen
Description

Operations

Data type

integer

Alias
UMLS CUI [1]
C0038895
Familienanamnese
Description

Family history

Data type

integer

Alias
UMLS CUI [1]
C0241889
Abusus
Description

Cigarette smoker

Data type

integer

Alias
UMLS CUI [1]
C0337667
Procedere
Description

Procedere

Alias
UMLS CUI-1
C0184661
ambulante Akte existiert
Description

File inpatient existing

Data type

boolean

Alias
UMLS CUI [1,1]
C0016094
UMLS CUI [1,2]
C0239966
stationäre Akte existiert
Description

File outpatient existing

Data type

boolean

Alias
UMLS CUI [1,1]
C0016094
UMLS CUI [1,2]
C0029921
OP-Bericht
Description

Operative report

Data type

boolean

Alias
UMLS CUI [1]
C1269801
Histologie
Description

Histopathology

Data type

boolean

Alias
UMLS CUI [1,1]
C0677043
UMLS CUI [1,2]
C0543467
Labor
Description

Laboratory Procedures

Data type

integer

Alias
UMLS CUI [1]
C0022885
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
Vaginale Untersuchung
Description

Vaginal Examination

Data type

text

Alias
UMLS CUI [1]
C0200048
Kolposkopie
Description

Colposcopy

Data type

integer

Alias
UMLS CUI [1]
C0009417
Sonographie
Description

Sonography

Data type

integer

Alias
UMLS CUI [1]
C0080264
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

General 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])
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])
Risk
Item
Risiken:
integer
C0035647 (UMLS CUI [1])
Item Group
Geburtshilfliche Anamnese
C1148523 (UMLS CUI-1)
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Geb.-Datum
date
C0421451 (UMLS CUI [1])
Gravidity and parity
Item
Para
integer
C0030563 (UMLS CUI [1])
Date of delivery
Item
Entbindungsdatum
date
C2053594 (UMLS CUI [1])
Time
Item
Geburtszeit
time
C0040223 (UMLS CUI [1])
Midwife
Item
Hebamme
integer
C0026083 (UMLS CUI [1])
Physician
Item
Arzt
integer
C2826892 (UMLS CUI [1])
Allergies
Item
Allergien:
integer
C0020517 (UMLS CUI [1])
Medication
Item
Dauermed.:
integer
C0013227 (UMLS CUI [1])
Symptoms
Item
Aktuelle Beschwerden:
text
C1457887 (UMLS CUI [1])
Clinical course
Item
Verlauf
text
C0449259 (UMLS CUI [1])
Diagnosis
Item
Diagnose
integer
C0011900 (UMLS CUI [1])
Diagnosis
Item
Diagnose
integer
C0011900 (UMLS CUI [1])
Therapy
Item
Therapie
integer
C0087111 (UMLS CUI [1])
Parity
Item
Para
integer
C0030563 (UMLS CUI [1])
Item
Operationen
integer
C0038895 (UMLS CUI [1])
Operations
Code List
Operationen
CL Item
Nachblutung (1)
C0347697 (UMLS CUI-1)
CL Item
Thrombose (2)
C0040053 (UMLS CUI-1)
CL Item
Transfusion (3)
C1879316 (UMLS CUI-1)
Family history
Item
Familienanamnese
integer
C0241889 (UMLS CUI [1])
Cigarette smoker
Item
Abusus
integer
C0337667 (UMLS CUI [1])
Item Group
Procedere
C0184661 (UMLS CUI-1)
File inpatient existing
Item
ambulante Akte existiert
boolean
C0016094 (UMLS CUI [1,1])
C0239966 (UMLS CUI [1,2])
File outpatient existing
Item
stationäre Akte existiert
boolean
C0016094 (UMLS CUI [1,1])
C0029921 (UMLS CUI [1,2])
Operative report
Item
OP-Bericht
boolean
C1269801 (UMLS CUI [1])
Histopathology
Item
Histologie
boolean
C0677043 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Item
Labor
integer
C0022885 (UMLS CUI [1])
Laboratory Procedures
Code List
Labor
CL Item
BB (1)
C0005771 (UMLS CUI-1)
CL Item
quick (2)
C0483455 (UMLS CUI-1)
CL Item
ptt (3)
C0030605 (UMLS CUI-1)
CL Item
Na (4)
C0337443 (UMLS CUI-1)
CL Item
K (5)
C0202194 (UMLS CUI-1)
CL Item
Ca (6)
C0201925 (UMLS CUI-1)
CL Item
Crea (7)
C0201976 (UMLS CUI-1)
CL Item
Got (8)
C0004002 (UMLS CUI-1)
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)
Vaginal Examination
Item
Vaginale Untersuchung
text
C0200048 (UMLS CUI [1])
Colposcopy
Item
Kolposkopie
integer
C0009417 (UMLS CUI [1])
Sonography
Item
Sonographie
integer
C0080264 (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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