ID

21967

Beschrijving

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

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  1. 10-05-17 10-05-17 -
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10 mei 2017

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General medical history Gynaecology UKM

Duits Engels

General medical history

1 Formulieren  
Patient demographics
Beschrijving

Patient demographics

Name
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Address
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Health insurance
Beschrijving

Health insurance

Datatype

integer

Alias
UMLS CUI [1]
C0021682
Address
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Physician
Beschrijving

Physician

Datatype

text

Alias
UMLS CUI [1]
C2826892
Risk
Beschrijving

Risk

Datatype

integer

Alias
UMLS CUI [1]
C0035647
Midwifery history
Beschrijving

Midwifery history

Alias
UMLS CUI-1
C1148523
Name
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Gravidity and parity
Beschrijving

Gravidity and parity

Datatype

integer

Alias
UMLS CUI [1]
C0030563
Date of delivery
Beschrijving

Date of delivery

Datatype

date

Alias
UMLS CUI [1]
C2053594
Time
Beschrijving

Time

Datatype

time

Alias
UMLS CUI [1]
C0040223
Midwife
Beschrijving

Midwife

Datatype

integer

Alias
UMLS CUI [1]
C0026083
Physician
Beschrijving

Physician

Datatype

integer

Alias
UMLS CUI [1]
C2826892
Medical history
Beschrijving

Medical history

Allergies
Beschrijving

Allergies

Datatype

integer

Alias
UMLS CUI [1]
C0020517
Medication
Beschrijving

Medication

Datatype

integer

Alias
UMLS CUI [1]
C0013227
Symptoms
Beschrijving

Symptoms

Datatype

text

Alias
UMLS CUI [1]
C1457887
Clinical course
Beschrijving

Clinical course

Datatype

text

Alias
UMLS CUI [1]
C0449259
Diagnosis
Beschrijving

Diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Diagnosis
Beschrijving

Diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Therapy
Beschrijving

Therapy

Datatype

integer

Alias
UMLS CUI [1]
C0087111
Parity
Beschrijving

Parity

Datatype

integer

Alias
UMLS CUI [1]
C0030563
Operations
Beschrijving

Operations

Datatype

integer

Alias
UMLS CUI [1]
C0038895
Family history
Beschrijving

Family history

Datatype

integer

Alias
UMLS CUI [1]
C0241889
Cigarette smoker
Beschrijving

Cigarette smoker

Datatype

integer

Alias
UMLS CUI [1]
C0337667
Procedure
Beschrijving

Procedure

Alias
UMLS CUI-1
C0184661
File inpatient existing
Beschrijving

File inpatient existing

Datatype

boolean

Alias
UMLS CUI [1,1]
C0016094
UMLS CUI [1,2]
C0239966
File outpatient existing
Beschrijving

File outpatient existing

Datatype

boolean

Alias
UMLS CUI [1,1]
C0016094
UMLS CUI [1,2]
C0029921
Operative report
Beschrijving

Operative report

Datatype

boolean

Alias
UMLS CUI [1]
C1269801
Histopathology
Beschrijving

Histopathology

Datatype

boolean

Alias
UMLS CUI [1,1]
C0677043
UMLS CUI [1,2]
C0543467
Laboratory Procedures
Beschrijving

Laboratory Procedures

Datatype

integer

Alias
UMLS CUI [1]
C0022885
Examination
Beschrijving

Examination

Genital
Beschrijving

Genital

Datatype

integer

Alias
UMLS CUI [1]
C0017420
Vagina
Beschrijving

Vagina

Datatype

integer

Alias
UMLS CUI [1]
C0042232
Cervix
Beschrijving

Cervix

Datatype

integer

Alias
UMLS CUI [1]
C0007874
Uterus
Beschrijving

Uterus

Datatype

integer

Alias
UMLS CUI [1]
C0007874
Uterine adnexae structure
Beschrijving

Uterine adnexae structure

Datatype

integer

Alias
UMLS CUI [1]
C0001575
Rectum
Beschrijving

Rectum

Datatype

integer

Alias
UMLS CUI [1]
C0001575
Mamma
Beschrijving

Mamma

Datatype

integer

Alias
UMLS CUI [1]
C1268990
Skin
Beschrijving

Skin

Datatype

integer

Alias
UMLS CUI [1]
C1268990
Head
Beschrijving

Head

Datatype

integer

Alias
UMLS CUI [1]
C1268990
Chest
Beschrijving

Chest

Datatype

integer

Alias
UMLS CUI [1]
C0817096
Heart
Beschrijving

Heart

Datatype

integer

Alias
UMLS CUI [1]
C0018787
Lungs
Beschrijving

Lungs

Datatype

integer

Alias
UMLS CUI [1]
C2228454
Abdomen
Beschrijving

Abdomen

Datatype

integer

Alias
UMLS CUI [1]
C0000726
Kindey
Beschrijving

Kidney

Datatype

integer

Alias
UMLS CUI [1]
C0022646
Limbs
Beschrijving

Limbs

Datatype

integer

Alias
UMLS CUI [1]
C0015385
Nerv
Beschrijving

Nerv

Datatype

integer

Alias
UMLS CUI [1]
C0027763
Vaginal Examination
Beschrijving

Vaginal Examination

Datatype

text

Alias
UMLS CUI [1]
C0200048
Colposcopy
Beschrijving

Colposcopy

Datatype

integer

Alias
UMLS CUI [1]
C0009417
Sonography
Beschrijving

Sonography

Datatype

integer

Alias
UMLS CUI [1]
C0080264
Footer module
Beschrijving

Footer module

Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Signature
Beschrijving

Signature

Datatype

text

Alias
UMLS CUI [1]
C1519316
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Similar models

General medical history

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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])
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])
Risk
Item
Risk
integer
C0035647 (UMLS CUI [1])
Item Group
Midwifery history
C1148523 (UMLS CUI-1)
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Gravidity and parity
Item
Gravidity and parity
integer
C0030563 (UMLS CUI [1])
Date of delivery
Item
Date of delivery
date
C2053594 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Midwife
Item
Midwife
integer
C0026083 (UMLS CUI [1])
Physician
Item
Physician
integer
C2826892 (UMLS CUI [1])
Item Group
Medical history
Allergies
Item
Allergies
integer
C0020517 (UMLS CUI [1])
Medication
Item
Medication
integer
C0013227 (UMLS CUI [1])
Symptoms
Item
Symptoms
text
C1457887 (UMLS CUI [1])
Clinical course
Item
Clinical course
text
C0449259 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Therapy
Item
Therapy
integer
C0087111 (UMLS CUI [1])
Parity
Item
Parity
integer
C0030563 (UMLS CUI [1])
Item
Operations
integer
C0038895 (UMLS CUI [1])
Operations
Code List
Operations
CL Item
secondary bleeding (1)
C0347697 (UMLS CUI-1)
CL Item
thrombosis (2)
C0040053 (UMLS CUI-1)
CL Item
transfusion (3)
C1879316 (UMLS CUI-1)
Family history
Item
Family history
integer
C0241889 (UMLS CUI [1])
Cigarette smoker
Item
Cigarette smoker
integer
C0337667 (UMLS CUI [1])
Item Group
Procedure
C0184661 (UMLS CUI-1)
File inpatient existing
Item
File inpatient existing
boolean
C0016094 (UMLS CUI [1,1])
C0239966 (UMLS CUI [1,2])
File outpatient existing
Item
File outpatient existing
boolean
C0016094 (UMLS CUI [1,1])
C0029921 (UMLS CUI [1,2])
Operative report
Item
Operative report
boolean
C1269801 (UMLS CUI [1])
Histopathology
Item
Histopathology
boolean
C0677043 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Item
Laboratory Procedures
integer
C0022885 (UMLS CUI [1])
Laboratory Procedures
Code List
Laboratory Procedures
CL Item
blood count (1)
C0005771 (UMLS CUI-1)
CL Item
quick (2)
C0483455 (UMLS CUI-1)
CL Item
ptt (3)
C0030605 (UMLS CUI-1)
CL Item
sodium (4)
C0337443 (UMLS CUI-1)
CL Item
potassium (5)
C0202194 (UMLS CUI-1)
CL Item
calcium (6)
C0201925 (UMLS CUI-1)
CL Item
crea (7)
C0201976 (UMLS CUI-1)
CL Item
got (8)
C0004002 (UMLS CUI-1)
Item Group
Examination
Item
Genital
integer
C0017420 (UMLS CUI [1])
Genital
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])
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
Uterine adnexae structure
integer
C0001575 (UMLS CUI [1])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
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])
Genital
Code List
Nerv
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Vaginal Examination
Item
Vaginal Examination
text
C0200048 (UMLS CUI [1])
Colposcopy
Item
Colposcopy
integer
C0009417 (UMLS CUI [1])
Sonography
Item
Sonography
integer
C0080264 (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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