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

Trefwoorden

Versies (1)
  1. 10-05-17 10-05-17 -
Houder van rechten

UKM

Geüploaded op

10 mei 2017

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

General medical history Gynaecology UKM

Duits Engels

General medical history

1 Formulieren  
Patientendaten
Beschrijving

Patientendaten

Name
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Geburtsdatum
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Addresse
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Antikörper
Beschrijving

Health insurance

Datatype

integer

Alias
UMLS CUI [1]
C0021682
Hebamme
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Arzt
Beschrijving

Physician

Datatype

text

Alias
UMLS CUI [1]
C2826892
Risiken:
Beschrijving

Risk

Datatype

integer

Alias
UMLS CUI [1]
C0035647
Geburtshilfliche Anamnese
Beschrijving

Geburtshilfliche Anamnese

Alias
UMLS CUI-1
C1148523
Name
Beschrijving

Name

Datatype

text

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

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Para
Beschrijving

Gravidity and parity

Datatype

integer

Alias
UMLS CUI [1]
C0030563
Entbindungsdatum
Beschrijving

Date of delivery

Datatype

date

Alias
UMLS CUI [1]
C2053594
Geburtszeit
Beschrijving

Time

Datatype

time

Alias
UMLS CUI [1]
C0040223
Hebamme
Beschrijving

Midwife

Datatype

integer

Alias
UMLS CUI [1]
C0026083
Arzt
Beschrijving

Physician

Datatype

integer

Alias
UMLS CUI [1]
C2826892
Medical history
Beschrijving

Medical history

Allergien:
Beschrijving

Allergies

Datatype

integer

Alias
UMLS CUI [1]
C0020517
Dauermed.:
Beschrijving

Medication

Datatype

integer

Alias
UMLS CUI [1]
C0013227
Aktuelle Beschwerden:
Beschrijving

Symptoms

Datatype

text

Alias
UMLS CUI [1]
C1457887
Verlauf
Beschrijving

Clinical course

Datatype

text

Alias
UMLS CUI [1]
C0449259
Diagnose
Beschrijving

Diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Diagnose
Beschrijving

Diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Therapie
Beschrijving

Therapy

Datatype

integer

Alias
UMLS CUI [1]
C0087111
Para
Beschrijving

Parity

Datatype

integer

Alias
UMLS CUI [1]
C0030563
Operationen
Beschrijving

Operations

Datatype

integer

Alias
UMLS CUI [1]
C0038895
Familienanamnese
Beschrijving

Family history

Datatype

integer

Alias
UMLS CUI [1]
C0241889
Abusus
Beschrijving

Cigarette smoker

Datatype

integer

Alias
UMLS CUI [1]
C0337667
Procedere
Beschrijving

Procedere

Alias
UMLS CUI-1
C0184661
ambulante Akte existiert
Beschrijving

File inpatient existing

Datatype

boolean

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

File outpatient existing

Datatype

boolean

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

Operative report

Datatype

boolean

Alias
UMLS CUI [1]
C1269801
Histologie
Beschrijving

Histopathology

Datatype

boolean

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

Laboratory Procedures

Datatype

integer

Alias
UMLS CUI [1]
C0022885
Erstuntersuchung
Beschrijving

Erstuntersuchung

äuß. Gen.
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
Adnexe
Beschrijving

Uterine adnexae structure

Datatype

integer

Alias
UMLS CUI [1]
C0001575
Rektum
Beschrijving

Rectum

Datatype

integer

Alias
UMLS CUI [1]
C0001575
Mamma
Beschrijving

Mamma

Datatype

integer

Alias
UMLS CUI [1]
C1268990
Haut
Beschrijving

Skin

Datatype

integer

Alias
UMLS CUI [1]
C1268990
Kopf
Beschrijving

Head

Datatype

integer

Alias
UMLS CUI [1]
C1268990
Thorax
Beschrijving

Chest

Datatype

integer

Alias
UMLS CUI [1]
C0817096
Herz
Beschrijving

Heart

Datatype

integer

Alias
UMLS CUI [1]
C0018787
Lunge
Beschrijving

Lungs

Datatype

integer

Alias
UMLS CUI [1]
C2228454
Abdomen
Beschrijving

Abdomen

Datatype

integer

Alias
UMLS CUI [1]
C0000726
Nieren
Beschrijving

Kidney

Datatype

integer

Alias
UMLS CUI [1]
C0022646
Extrem.
Beschrijving

Limbs

Datatype

integer

Alias
UMLS CUI [1]
C0015385
Nerven
Beschrijving

Nerv

Datatype

integer

Alias
UMLS CUI [1]
C0027763
Vaginale Untersuchung
Beschrijving

Vaginal Examination

Datatype

text

Alias
UMLS CUI [1]
C0200048
Kolposkopie
Beschrijving

Colposcopy

Datatype

integer

Alias
UMLS CUI [1]
C0009417
Sonographie
Beschrijving

Sonography

Datatype

integer

Alias
UMLS CUI [1]
C0080264
Unterschrift
Beschrijving

Unterschrift

Datum
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Unterschrift
Beschrijving

Signature

Datatype

text

Alias
UMLS CUI [1]
C1519316
Terug naar het begin van de pagina

Similar models

General medical history

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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])
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial