ID
22558
Description
Form from HIS OpenVista
Keywords
Versions (2)
- 3/9/12 3/9/12 -
- 6/8/17 6/8/17 - Martin Dugas
Uploaded on
June 8, 2017
DOI
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License
Creative Commons BY-NC 3.0
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NURSING ASSESSMENT (adult)
HIS
- StudyEvent: HIS
Description
Neuro / Psychosocial
Alias
- UMLS CUI-1
- C0746866
Description
Neurological examination normal
Data type
boolean
Alias
- UMLS CUI [1]
- C1112287
Description
Abnormal Findings
Data type
text
Alias
- UMLS CUI [1]
- C1704258
Description
GLASGOW COMA SCALE ADULT
Alias
- UMLS CUI-1
- C1271007
Description
Eyes open
Data type
integer
Alias
- UMLS CUI [1]
- C3648956
Description
BEST VERBAL RESPONSE
Data type
integer
Alias
- UMLS CUI [1]
- C3648957
Description
BEST MOTOR RESPONSE
Data type
integer
Alias
- UMLS CUI [1]
- C3648958
Description
GLASCOW COMA SCALE SCORE
Data type
integer
Alias
- UMLS CUI [1]
- C1271007
Description
Pupils
Alias
- UMLS CUI-1
- C0034121
Description
Right Pupil Size
Data type
integer
Measurement units
- mm
Alias
- UMLS CUI [1,1]
- C0517965
- UMLS CUI [1,2]
- C0205090
Description
Right Pupil Reaction
Data type
text
Alias
- UMLS CUI [1,1]
- C0234671
- UMLS CUI [1,2]
- C0444532
Description
Left Pupil Size
Data type
integer
Measurement units
- mm
Alias
- UMLS CUI [1,1]
- C0517965
- UMLS CUI [1,2]
- C0205091
Description
Left Pupil Reaction
Data type
text
Alias
- UMLS CUI [1,1]
- C0234671
- UMLS CUI [1,2]
- C0443246
Description
ORIENTATION
Alias
- UMLS CUI-1
- C0029266
Description
ORIENTATION
Data type
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Description
History of SEIZURE ACTIVITY
Data type
text
Alias
- UMLS CUI [1]
- C1148156
Description
AFFECT
Data type
string
Alias
- UMLS CUI 2011AA
- C0001721
- SNOMED CT 2011_0131
- 4065008
Description
SPEECH
Data type
string
Alias
- UMLS CUI 2011AA
- C0037817
- SNOMED CT 2011_0131
- 87335007
- LOINC Version 232
- MTHU021528
Description
NUMBNESS OR TINGLING
Data type
text
Alias
- UMLS CUI [1]
- C3842982
Description
Cardiovascular system
Alias
- UMLS CUI-1
- C0007226
Description
Cardiovascular system normal
Data type
boolean
Alias
- UMLS CUI [1]
- C0577867
Description
Abnormal Findings
Data type
text
Alias
- UMLS CUI [1]
- C1704258
Description
Antithromboembolic stockings
Data type
boolean
Alias
- UMLS CUI [1]
- C0419312
Description
Vascular Sequential Compression Devices
Data type
boolean
Alias
- UMLS CUI [1]
- C0180062
Description
HEART SOUNDS
Data type
string
Alias
- UMLS CUI 2011AA
- C0018820
- SNOMED CT 2011_0131
- 23472005
Description
Radial pulse (L/R)
Data type
string
Alias
- UMLS CUI 2011AA
- C0232142
- SNOMED CT 2011_0131
- 65452004
- MedDRA 14.1
- 10053935
Description
Pedal pulse
Data type
text
Alias
- UMLS CUI [1]
- C0232157
Description
Pos-Tibial Pulse (L/R)
Data type
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Description
Popliteal Pulse (L/R)
Data type
string
Alias
- UMLS CUI 2011AA
- C0232151
- SNOMED CT 2011_0131
- 74828005
- MedDRA 14.1
- 10053938
Description
Brachial Pulse (L/R)
Data type
string
Alias
- UMLS CUI 2011AA
- C1096531
- MedDRA 14.1
- 10053929
Description
Carotid Pulse (L/R)
Data type
string
Alias
- UMLS CUI 2011AA
- C1096529
- MedDRA 14.1
- 10053926
Description
AV SHUNT
Data type
text
Alias
- UMLS CUI [1]
- C1456474
Description
BRUIT
Data type
text
Alias
- UMLS CUI [1]
- C0006318
Description
SHUNT BRUIT
Data type
text
Alias
- UMLS CUI [1]
- C0232112
Description
THRILL
Data type
text
Alias
- UMLS CUI [1]
- C2678517
Description
CAPILLARY REFILL
Data type
text
Alias
- UMLS CUI [1]
- C0425716
Description
NAIL BED COLOR
Data type
text
Alias
- UMLS CUI [1]
- C0574757
Description
Edema
Data type
string
Alias
- UMLS CUI 2011AA
- C0013604
- SNOMED CT 2011_0131
- 423666004
- MedDRA 14.1
- 10030095
- LOINC Version 232
- MTHU019803
- ICD-10-CM Version 2010
- R60.9
- ICD-9-CM Version 2011
- 782.3
Description
Heart RHYTHM
Data type
text
Alias
- UMLS CUI [1]
- C0232187
Description
PACEMAKER PRESENT
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0030163
- SNOMED CT 2011_0131
- 14106009
- LOINC Version 232
- MTHU024521
Description
Eyes Ear Nose & Throat
Description
NORMAL BASELINE EYES
Data type
boolean
Description
Normal Baseline Ears
Data type
boolean
Description
Normal Baseline Nose
Data type
boolean
Description
Normal Baseline Throat
Data type
boolean
Description
NARRATIVE: Abnormal Findings
Data type
string
Description
Eyes
Description
Pupil Right Size [mm]
Data type
integer
Description
Pupil Right Reaction
Data type
string
Description
Pupil Left Size [mm]
Data type
integer
Description
Pupil Left Reaction
Data type
string
Description
Eye Complains
Data type
string
Description
Right Sclera
Data type
string
Description
Left Sclera
Data type
string
Description
Drainage
Data type
boolean
Description
Drainage Color
Data type
string
Description
EARS
Description
EARS(EXTERNAL CANAL)
Data type
string
Description
C/O Pain
Data type
boolean
Description
Tempanic Membranes
Data type
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Description
Tubes
Data type
string
Description
Hard of Hearing
Data type
boolean
Description
Hearing Loss
Data type
boolean
Description
Deafness
Data type
boolean
Description
Hearing Aids
Data type
string
Description
Patent
Data type
boolean
Description
Dizziness
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0012833
- SNOMED CT 2011_0131
- 404640003
- MedDRA 14.1
- 10013573
- CTCAE 1105E
- E12631
Description
Tinnitus
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0040264
- SNOMED CT 2011_0131
- 60862001
- MedDRA 14.1
- 10043882
- ICD-10-CM Version 2010
- H93.1
- ICD-9-CM Version 2011
- 388.3
- CTCAE 1105E
- E10287
Description
Drainage
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Description
Color of Ear Drainage
Data type
string
Description
Nose
Description
Pharynx, Throat
Description
Throat Pain
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0242429
- SNOMED CT 2011_0131
- 267102003
- MedDRA 14.1
- 10041367
- ICD-10-CM Version 2010
- R07.0
- ICD-9-CM Version 2011
- 784.1
- CTCAE 1105E
- E13575
Description
Mouth Sores
Data type
boolean
Description
Appearance of Throat
Data type
string
Description
Mucous Membranes
Data type
string
Description
Respiratory
Description
NORMAL BASELINE
Data type
boolean
Description
NARRATIVE: Abnormal Findings
Data type
string
Description
BREATH SOUNDS
Data type
string
Alias
- UMLS CUI 2011AA
- C0035234
- SNOMED CT 2011_0131
- 52653008
- MedDRA 14.1
- 10064779
Description
RESPIRATORY EFFORT
Data type
string
Description
CHEST EXPANSION
Data type
string
Description
INCENTIVE SPIROMETRY DONE
Data type
boolean
Description
OXYGEN DELIVERY METHOD
Data type
string
Description
Pulse Oximeter present with alarms set
Data type
boolean
Description
Cardio-Respriratory Monitor present with alarms set
Data type
boolean
Description
COUGH TYPE
Data type
string
Alias
- UMLS CUI 2011AA
- C0010200
- SNOMED CT 2011_0131
- 49727002
- MedDRA 14.1
- 10011224
- ICD-10-CM Version 2010
- R05
- ICD-9-CM Version 2011
- 786.2
- CTCAE 1105E
- E13364
Description
Sputum (incl. Quantity)
Data type
string
Alias
- UMLS CUI 2011AA
- C0038056
- SNOMED CT 2011_0131
- 45710003
- MedDRA 14.1
- 10041802
- LOINC Version 232
- MTHU001309
Description
CHEST TUBE PRESENT
Data type
boolean
Description
CHEST TUBE LOCATION
Data type
boolean
Description
Chest Tube Suction Setting
Data type
string
Description
Air Leak
Data type
string
Description
Gastrointestinal
Description
NORMAL BASELINE GI
Data type
boolean
Description
Last BM
Data type
date
Description
NARRATIVE: Abnormal Findings
Data type
string
Description
ABDOMINAL DESCRIPTION
Data type
string
Alias
- UMLS CUI 2011AA
- C0000726
- SNOMED CT 2011_0131
- 113345001
- LOINC Version 232
- MTHU001425
Description
BOWEL SOUNDS
Data type
string
Alias
- UMLS CUI 2011AA
- C0232693
- SNOMED CT 2011_0131
- 87042004
- MedDRA 14.1
- 10006023
Description
FLATUS
Data type
boolean
Description
GASTRIC SYMPTOMS
Data type
string
Description
NARES
Data type
string
Description
NG TUBE TYPE
Data type
string
Description
NG placement checked
Data type
boolean
Description
Suction Setting
Data type
string
Description
Gastric Content Color
Data type
string
Description
NGT irrigated
Data type
string
Description
OSTOMY TYPE
Data type
string
Description
RECTAL BAG PRESENT
Data type
boolean
Description
Genitourinary system, Urogenital system
Description
NORMAL BASELINE
Data type
boolean
Description
NARRATIVE: Abnormal Findings
Data type
string
Description
Sex
Data type
string
Alias
- UMLS CUI 2011AA
- C0079399
- SNOMED CT 2011_0131
- 263495000
- LOINC Version 232
- MTHU002975
Description
INCONTINENT
Data type
boolean
Description
VOIDS SUFFICIENT QUANITY
Data type
boolean
Description
IS PATIENT RECEIVING DIALYSIS
Data type
boolean
Description
ODOR PRESENT
Data type
boolean
Description
URINE COLOR
Data type
string
Description
CATHETER PRESENT
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0085590
- SNOMED CT 2011_0131
- 19923001
Description
CATHETER SIZE
Data type
string
Alias
- UMLS CUI 2011AA
- C0449963
- SNOMED CT 2011_0131
- 260967009
Description
Date of insertion
Data type
date
Description
Urine color
Data type
string
Description
URINARY SYMPTOMS
Data type
string
Description
SEXUALLY ACTIVE
Data type
boolean
Description
CURRENTLY ON MENSES
Data type
boolean
Description
DISCHARGE PRESENT
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0012621
- SNOMED CT 2011_0131
- 75823008
Description
Discharge color
Data type
string
Description
Discharge odor
Data type
string
Description
Discharge consistency
Data type
string
Description
ABNORMAL GENITALIA DESCRIPTION
Data type
string
Description
Musculoskeletal System, Musculo-skeletal system
Description
NORMAL BASELINE
Data type
boolean
Description
NARRATIVE: Abnormal Findings
Data type
string
Description
GENERALIZED WEAKNESS
Data type
boolean
Description
LIMITED ROM
Data type
boolean
Description
LIMITED MOBILITY
Data type
boolean
Description
CONTRACTURES
Data type
boolean
Description
FRACTURE(S) LOCATION
Data type
string
Description
FINGER DIGITS
Data type
string
Description
TOE DIGITS
Data type
string
Description
PARALYSIS TYPE
Data type
string
Description
Hemiplegia Side
Data type
string
Description
LEFT UPPER EXTREMITIES
Data type
string
Description
RIGHT UPPER EXTREMITIES
Data type
string
Description
GRIPS EQUAL
Data type
boolean
Description
LEFT LOWER EXTREMITIES
Data type
string
Description
RIGHT LOWER EXTREMITIES
Data type
string
Description
UNSTEADY GAIT
Data type
boolean
Description
Integument
Description
NORMAL BASELINE
Data type
boolean
Description
NARRATIVE: Abnormal Findings
Data type
string
Description
SKIN COLOR
Data type
string
Description
TEMPERATURE
Data type
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Description
MOIST
Data type
boolean
Description
SKIN TURGOR
Data type
string
Description
RASH LOCATION
Data type
string
Description
RASH DESCRIPTION
Data type
string
Description
TATTOO'S/PIERCINGS
Data type
string
Description
SKIN TEARS, LOCATION/ Description
Data type
string
Description
PRESSURE ULCER ASSESSMENT
Description
Bony Prominences Assessed
Data type
boolean
Description
At risk for skin breakdown
Data type
boolean
Description
Braden Score 18 or less
Data type
boolean
Description
Pressure ulcer(s) present
Data type
boolean
Description
ULCER #
Data type
string
Description
Ulcer LOCATION
Data type
string
Description
ULCER STAGE
Data type
string
Description
Ulcer Length
Data type
string
Description
Ulcer Width
Data type
string
Description
Ulcer Depth
Data type
string
Description
Wound
Description
WOUND #
Data type
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
Description
Wound healed
Data type
boolean
Description
Wound Location
Data type
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Description
Length (cm, mm)
Data type
string
Description
Width (cm, mm)
Data type
string
Description
Depth (cm, mm)
Data type
string
Description
Undermining
Data type
boolean
Description
Tunneling
Data type
boolean
Description
Surrounding Skin
Data type
string
Description
Wound Base
Data type
string
Description
Exudate
Data type
string
Alias
- UMLS CUI 2011AA
- C0015388
- SNOMED CT 2011_0131
- 247450001
- LOINC Version 232
- MTHU025016
Description
Exudate Color
Data type
string
Description
Sensation
Data type
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Description
Odor: Before Cleaning
Data type
boolean
Description
Odor: After Cleaning
Data type
boolean
Description
Cleansed with/irrigated with
Data type
string
Description
Hemostasis Achieved with
Data type
string
Description
Wound Medication Applied
Data type
string
Description
Wound Filled with
Data type
string
Description
Wound covered with
Data type
string
Description
Wound secured with
Data type
string
Description
Wound Pressure Relief
Data type
string
Description
Comments
Data type
string
Description
Photograph Date
Data type
date
Description
Surgical incision
Description
Incision #:
Data type
string
Alias
- UMLS CUI 2011AA
- C0184898
- SNOMED CT 2011_0131
- 34896006
Description
MID WOUND#
Data type
string
Description
Site
Data type
string
Description
Closure Type
Data type
string
Description
Incision Appearance
Data type
string
Description
Dressing Changed
Data type
boolean
Description
Date Dressing Changed
Data type
date
Description
Dressing Type
Data type
string
Description
Dressing Appearance
Data type
string
Description
Drains
Data type
string
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Description
Nutrition
Description
Current Diet
Data type
string
Alias
- UMLS CUI 2011AA
- C0012155
- SNOMED CT 2011_0131
- 41829006
Description
FEEDING TUBE PRESENT
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0041281
- SNOMED CT 2011_0131
- 61420007
- MedDRA 14.1
- 10053095
Description
Feeding Tube Type
Data type
string
Description
Formula
Data type
string
Description
RESIDUALS CHECKED
Data type
string
Description
NPO
Data type
boolean
Description
BREAKFAST
Data type
string
Description
Breakfast: Amount taken
Data type
string
Description
Breakfast: Patient fed by
Data type
string
Description
LUNCH
Data type
string
Description
Lunch: Amount taken
Data type
string
Description
Lunch: Patient fed by
Data type
string
Description
SUPPER
Data type
string
Description
Supper: Amount taken
Data type
string
Description
Supper: Patient fed by
Data type
string
Description
Supper: Amount taken
Data type
string
Description
intravenous therapy
Description
NARRATIVE: IV Therapy
Data type
string
Description
IV HEPLOCKED
Data type
boolean
Description
IV Site APPEARANCE
Data type
string
Description
IV DISCONTINUED
Data type
boolean
Description
CATHETER INTACT
Data type
boolean
Description
IV Catheter Size
Data type
string
Description
IV Site Location
Data type
string
Description
CENTRAL LINE PORT
Data type
string
Alias
- UMLS CUI 2011AA
- C1145640
- SNOMED CT 2011_0131
- 52124006
Description
IV FLUIDS
Data type
string
Alias
- UMLS CUI 2011AA
- C1289919
- SNOMED CT 2011_0131
- 118431008
- MedDRA 14.1
- 10067708
Description
Left to count:
Data type
string
Description
IV Fluid Rate: @ ml/hr
Data type
integer
Description
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Data type
string
Description
PCA PUMP: at @ cc's/hr
Data type
string
Description
IV Site APPEARANCE
Data type
string
Description
INSERTION DATE
Data type
date
Description
DRESSING CHANGE DUE
Data type
date
Description
SITE CHANGE DUE
Data type
date
Description
PLACED ON IMED
Data type
boolean
Description
patient safety
Description
SIDE RAILS UP
Data type
boolean
Description
IN LOW POSTION
Data type
boolean
Description
BED/CRIB
Data type
string
Description
CALL BELL WITHIN REACH
Data type
boolean
Description
ALLERGY BAND ON
Data type
boolean
Description
NAME BAND ON
Data type
boolean
Description
BLOOD BAND ON
Data type
boolean
Description
BED SAFETY
Data type
string
Description
Hendrich II Fall Risk Assessment
Description
Unable to assess fall risk status at this time due to patient is:
Data type
string
Description
Confusion/Disorientation/Impulsivity +4
Data type
boolean
Description
Symptomatic Depression +2
Data type
boolean
Description
Altered Elimination +1
Data type
boolean
Description
Dizziness/Vertigo +1
Data type
boolean
Description
Gender (male) +1
Data type
boolean
Description
Any Administered Antiepileptics (Anticonvulsants) +2
Data type
boolean
Description
Any Administered Benzodiazepines +1
Data type
boolean
Description
GET UP AND GO TEST: RISING FROM A CHAIR
Data type
integer
Description
FINAL Hendrich II RISK SCORE
Data type
integer
Description
INTERVENTIONS
Description
Assist with Ambulation
Data type
boolean
Description
Reorient Q2H or Less
Data type
boolean
Description
Gait Belt
Data type
boolean
Description
ID Patient at Risk
Data type
boolean
Description
Restraints (see policy)
Data type
boolean
Description
Multi-personnel Transfer
Data type
boolean
Description
Close Observation
Data type
boolean
Description
Non-slip Footwear
Data type
boolean
Description
Bed in lowest position
Data type
boolean
Description
Lock wheels of vehicles of conveyance during transfer
Data type
boolean
Description
Upper siderails raised
Data type
boolean
Description
Call light in reach
Data type
boolean
Description
Assist with ambulation
Data type
boolean
Description
Offer toileting at least every 2 hours
Data type
boolean
Description
Offer fluid/nutrition every 2 hours
Data type
boolean
Description
Place frequently used objects within reach
Data type
boolean
Description
Provide adequate lighting
Data type
boolean
Description
Provide sensory impairment/orientation devices (clocks,etc)
Data type
boolean
Description
Provide adequate rest periods
Data type
boolean
Description
Use age appropriate distractions for confusion/disorientation
Data type
boolean
Description
Remove harmful hazards
Data type
boolean
Description
Provide appropriate and least restrictive patient supervision/surveillance
Data type
boolean
Description
Communicate information about fall risk to caregivers
Data type
boolean
Description
Encourage family/support system to participate in care
Data type
boolean
Description
Teach/educate family/support system Fall Prevention information
Data type
boolean
Description
Implement Fall Prevention Protocol for Hendrich II Score>5
Data type
boolean
Description
IMPAIRED MOBILITY RISK
Description
Implement Universal Fall Prevention Intervention
Data type
boolean
Description
Monitor transfers to/from bed/chair(etc.)
Data type
boolean
Description
Use appropriate assistance for transfers to/from bed/chair
Data type
boolean
Description
Use chairs with armrests and of proper height for transfers
Data type
boolean
Description
Implement progressive ambulation(unless contraindicated by condition/orders)
Data type
boolean
Description
Encourage/Provide self-care assistance
Data type
boolean
Description
Remain in attendance during toileting/ADL's
Data type
boolean
Description
Provide assistive devices for ambulation (canes/walkers/etc.)
Data type
boolean
Description
Gait Belt during transport/ambulation
Data type
boolean
Description
Teach patient/family to call for help and WAIT for help before
Data type
boolean
Description
attempting any transfer/ambulation
Data type
boolean
Description
ALTERED ELIMINATION
Description
Implement Universal Fall Prevention Interventions
Data type
boolean
Description
Remain in attendance during toileting/ADL's
Data type
boolean
Description
Assist with post-elimination hygiene
Data type
boolean
Description
Remove non-essential clothing
Data type
boolean
Description
Instruct patient on importance of toileting when offered by staff
Data type
boolean
Description
Monitor for 'patient's normal' bladder/bowel habits
Data type
boolean
Description
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Data type
boolean
Description
Monitor skin integrity
Data type
boolean
Description
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Description
Implement Universal Fall Prevention Interventions
Data type
boolean
Description
Monitor drug dosages
Data type
boolean
Description
Evaluate sensory functions
Data type
boolean
Description
Monitor/Assess for drug overdose
Data type
boolean
Description
Monitor response to exercise
Data type
boolean
Description
Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
Data type
boolean
Description
INTERVENTIONS (FOR ONCOLOGY USE ONLY)
Description
UNIVERSAL FALL PRECAUTIONS
Data type
boolean
Description
Neutropenic Precautions taken.
Data type
boolean
Description
Date of last chemotherapy cycle
Data type
date
Description
Chemotherapy Agent/Dosage
Data type
string
Description
day of chemotherapy
Data type
integer
Description
Chemotherapy ADVERSE EFFECTS
Data type
string
Description
Radiation Safety Precautions taken.
Data type
boolean
Description
RADIATION INTERNAL
Data type
string
Description
Radiation External: Location of Markings
Data type
string
Description
Radiation: Number of Fractions prescribed
Data type
string
Description
Remaining Radiations
Data type
string
Description
Radiation Adverse Effects
Data type
string
Description
ONN Unit specific
Description
AFFECTED SITE
Data type
string
Description
CIRCULATORY STATUS
Data type
string
Description
SKIN COLOR
Data type
string
Description
SENSATION
Data type
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Description
MOVEMENT
Data type
string
Description
TEMPERATURE
Data type
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Description
SKIN CONDITION
Data type
string
Alias
- UMLS CUI 2011AA
- C1719933
- SNOMED CT 2011_0131
- 422000003
- LOINC Version 232
- MTHU034830
Description
PULSE(s) SITE(s)
Data type
string
Description
RESPONSE
Data type
string
Description
POSITION OF LIMB
Data type
string
Description
ORTHOPEDIC DEVICE IN USE
Data type
string
Description
CONTINUOUS PASSIVE MOTION
Data type
string
Description
POUNDS
Data type
string
Description
CERVICAL COLLARS
Data type
string
Description
AFO BRACE: Foot/Feet
Data type
string
Description
SWELLING
Data type
string
Description
PIN SITES
Data type
string
Description
CLEANED WITH
Data type
string
Description
NARRATIVE
Data type
string
Description
Antepartum specific
Description
Gravida
Data type
integer
Description
Para
Data type
integer
Description
EDC
Data type
date
Description
Weeks gestation
Data type
integer
Description
Fetal movement
Data type
boolean
Description
FHR
Data type
string
Description
Vision
Data type
string
Description
Headaches
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0018681
- SNOMED CT 2011_0131
- 25064002
- MedDRA 14.1
- 10019211
- LOINC Version 232
- MTHU020860
- ICD-10-CM Version 2010
- R51
- ICD-9-CM Version 2011
- 784.0
- CTCAE 1105E
- E12678
Description
Abdominal Cramps
Data type
boolean
Description
Uterine Contraction
Data type
boolean
Description
Epigastric Pain
Data type
boolean
Description
Vaginal Discharge
Data type
boolean
Description
Additional Findings
Data type
string
Description
Fundal Height
Data type
integer
Description
NARRATIVE: Antepartum
Data type
string
Description
Post partum specific
Description
Fundal Location
Data type
string
Description
LOCHIA
Data type
string
Description
Perineum
Data type
string
Description
BREASTS
Data type
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Description
NIPPLES
Data type
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Description
Mother/Baby Relationship
Data type
string
Description
BONDING
Data type
string
Description
Feedings
Data type
string
Description
Hemorrhoids
Data type
string
Alias
- UMLS CUI 2011AA
- C0019112
- SNOMED CT 2011_0131
- 70153002
- MedDRA 14.1
- 10019022
- LOINC Version 232
- MTHU015043
- ICD-10-CM Version 2010
- I84
- ICD-9-CM Version 2011
- 455
- CTCAE 1105E
- E10773
Description
NARRATIVE: Post partum
Data type
string
Description
Post Surgical
Description
General Activity
Data type
string
Alias
- UMLS CUI 2011AA
- C0451369
- SNOMED CT 2011_0131
- 273688003
Description
Vaginal Packing
Data type
string
Description
Equipment/Devices
Data type
string
Description
EQUIPMENT/DEVICES
Data type
string
Description
ADOLESCENT INTERACTION
Description
Prepared for treatment/procedure as soon as possible.
Data type
string
Description
Provided detailed information about events/procedures/treatments.
Data type
string
Description
Allowed contact with peer group.
Data type
string
Description
NARRATIVE
Data type
string
Description
GERIATRIC INTERVENTION (65+)
Description
Involved in decision process regarding pain control/medication/care decisions
Data type
string
Description
Encouraged family/S.O.to visit
Data type
string
Description
Independence promoted.
Data type
string
Description
NARRATIVE
Data type
string
Description
Hendrich Fall Risk
Description
Confusion/Disorientation +3
Data type
boolean
Description
Depression +4
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0011581
- SNOMED CT 2011_0131
- 35489007
- MedDRA 14.1
- 10012401
- ICD-10-CM Version 2010
- F32.9
Description
Altered Elimination (incontinence, nocturia) +3
Data type
boolean
Description
Non-Adaptive Mobility/Generalized Weakness +2
Data type
boolean
Description
Dizziness/Vertigo +3
Data type
boolean
Description
Primary Cancer Diagnosis +3
Data type
boolean
Alias
- UMLS CUI 2011AA
- C0006826
- SNOMED CT 2011_0131
- 363346000
- MedDRA 14.1
- 10028997
- LOINC Version 232
- MTHU010328
- ICD-10-CM Version 2010
- C00-C96
Description
RECENT HISTORY of FALLS +7
Data type
boolean
Description
FINAL Hendrich Fall RISK SCORE
Data type
integer
Description
SUGGESTED INTERVENTIONS
Description
Assist with Ambulation
Data type
string
Description
Toileting Q2H
Data type
string
Description
Sensory Impairment Device
Data type
string
Description
Reorient Q2H or Less
Data type
string
Description
Gait Belt
Data type
string
Description
ID Patient at Risk
Data type
string
Description
Restraints (see policy)
Data type
string
Description
Multi-personnel Transfer
Data type
string
Description
Close Observation
Data type
string
Description
Non-slip Footwear
Data type
string
Similar models
HIS
- StudyEvent: HIS
C0205090 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,2])
43173001 (SNOMED CT 2011_0131)
4065008 (SNOMED CT 2011_0131)
23472005 (SNOMED CT 2011_0131)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
421568004 (SNOMED CT 2011_0131)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
10053929 (MedDRA 14.1)
10053926 (MedDRA 14.1)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
60862001 (SNOMED CT 2011_0131)
10043882 (MedDRA 14.1)
H93.1 (ICD-10-CM Version 2010)
388.3 (ICD-9-CM Version 2011)
E10287 (CTCAE 1105E)
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
49727002 (SNOMED CT 2011_0131)
10011224 (MedDRA 14.1)
R05 (ICD-10-CM Version 2010)
786.2 (ICD-9-CM Version 2011)
E13364 (CTCAE 1105E)
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
19923001 (SNOMED CT 2011_0131)
260967009 (SNOMED CT 2011_0131)
75823008 (SNOMED CT 2011_0131)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
34896006 (SNOMED CT 2011_0131)
41829006 (SNOMED CT 2011_0131)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
52124006 (SNOMED CT 2011_0131)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
25064002 (SNOMED CT 2011_0131)
10019211 (MedDRA 14.1)
MTHU020860 (LOINC Version 232)
R51 (ICD-10-CM Version 2010)
784.0 (ICD-9-CM Version 2011)
E12678 (CTCAE 1105E)
24142002 (SNOMED CT 2011_0131)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
273688003 (SNOMED CT 2011_0131)
35489007 (SNOMED CT 2011_0131)
10012401 (MedDRA 14.1)
F32.9 (ICD-10-CM Version 2010)
363346000 (SNOMED CT 2011_0131)
10028997 (MedDRA 14.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)