ID

17657

Description

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Spezielle dermatologische Anamnese stationär

Keywords

Versions (1)
  1. 9/27/16 9/27/16 -
Uploaded on

September 27, 2016

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Inpatient medical history: Dermatologic specialty University Hospital Muenster (UKM)

German

Inpatient medical history: Dermatologic specialty, University hospital muenster (UKM)

1 forms  
Demographische Informationen
Description

Demographische Informationen

Name
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Vorname
Description

Given name

Data type

text

Alias
UMLS CUI [1]
C1443235
Geburtsdatum
Description

Birth Date

Data type

date

Alias
UMLS CUI [1]
C0421451
Geschlecht
Description

Gender

Data type

integer

Alias
UMLS CUI [1]
C0079399
Fall Nummer
Description

Case number

Data type

integer

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C0600091
Aufnahmedatum und Uhrzeit
Description

Date and time of admission

Data type

datetime

Alias
UMLS CUI [1,1]
C1302393
UMLS CUI [1,2]
C3854259
Einweisungsdiagnose
Description

Admission diagnosis

Data type

text

Alias
UMLS CUI [1]
C1628992
Spezifische Anamnese und Körperliche Untersuchung
Description

Spezifische Anamnese und Körperliche Untersuchung

Hauptbeschwerden
Description

Chief complaint

Data type

text

Alias
UMLS CUI [1]
C0277786
Bisherige Therapie
Description

Current therapy

Data type

text

Alias
UMLS CUI [1]
C0087111
Hautbefund
Description

Skin examination

Data type

text

Alias
UMLS CUI [1]
C0436149
Befallene Areale (in Grafik einzeichnen)
Description

wenn mehrere verschiedene HV, dann Lokalisationen (1...5) getrennt markieren

Data type

text

Alias
UMLS CUI [1]
C1879646
Dermographismus
Description

Dermographism

Data type

integer

Alias
UMLS CUI [1]
C0343065
Urticaria factitia
Description

Urticaria factitia

Data type

boolean

Alias
UMLS CUI [1]
C0152162
Urticaria factitia: Wenn ja, bitte spezifizieren
Description

Urticaria factitia

Data type

text

Alias
UMLS CUI [1]
C0152162
Atopische Diathese
Description

Atopic Diathesis

Data type

integer

Alias
UMLS CUI [1]
C0392707
Pruritus
Description

Pruritus

Data type

integer

Alias
UMLS CUI [1]
C0033774
Schleimhautbeteiligung
Description

Mucous Membranes involvement

Data type

boolean

Alias
UMLS CUI [1,1]
C0026724
UMLS CUI [1,2]
C0449730
Schleimhautbeteiligung: Wenn ja, bitte spezifizieren
Description

Mucous Membranes involvement

Data type

text

Alias
UMLS CUI [1,1]
C0026724
UMLS CUI [1,2]
C0449730
Allergien: Typ 1
Description

Hypersensitivities

Data type

boolean

Alias
UMLS CUI [1]
C0020517
Allergien: Typ 1 Wenn ja, bitte spezifizieren
Description

Hypersensitivities

Data type

text

Alias
UMLS CUI [1]
C0020517
Kontaktallergien
Description

Contact hypersensitivity

Data type

boolean

Alias
UMLS CUI [1]
C0162351
Kontaktallergien:Wenn ja, bitte spezifizieren
Description

Contact hypersensitivity

Data type

text

Alias
UMLS CUI [1]
C0162351
AI-Symptome
Description

AI-Symptoms

Data type

integer

Alias
UMLS CUI [1,1]
C0443146
UMLS CUI [1,2]
C0037088
Kutane Neoplasien
Description

Cutaneous neoplasm

Data type

boolean

Alias
UMLS CUI [1]
C0037286
Kutane Neoplasien: Wenn ja, bitte spezifizieren
Description

Cutaneous neoplasm

Data type

text

Alias
UMLS CUI [1]
C0037286
Dermatologische Familienanamnese
Description

Dermatologic family medical history

Data type

boolean

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0205489
Dermatologische Familienanamnese: Wenn ja, bitte spezifizieren
Description

Dermatologic family medical history

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0205489
Relevante Vorerkrankungen
Description

Relevante Vorerkrankungen

Cor
Description

Cor

Data type

text

Alias
UMLS CUI [1]
C0018787
Pulmo
Description

Pulmo

Data type

text

Alias
UMLS CUI [1]
C0024109
GIT/Leber:
Description

Gastrointestinal tract / liver

Data type

text

Alias
UMLS CUI [1]
C0017189
UMLS CUI [2]
C0023884
Urogenitaltrakt/Niere
Description

Genitourinary system/ kidneys

Data type

text

Alias
UMLS CUI [1]
C0042066
UMLS CUI [2]
C0227665
Schilddrüse
Description

Thyroid Gland

Data type

text

Alias
UMLS CUI [1]
C0040132
Diabetes mellitus
Description

Diabetes mellitus

Data type

text

Alias
UMLS CUI [1]
C0011849
Chron. Infektionen
Description

Chronic infections

Data type

text

Alias
UMLS CUI [1]
C0151317
Hämatologische Erkrankungen
Description

Hematologic diseases

Data type

text

Alias
UMLS CUI [1]
C0018939
Tumor
Description

Neoplasm

Data type

text

Alias
UMLS CUI [1]
C0027651
Neurologische Erkrankungen
Description

Neurologic diseases

Data type

text

Alias
UMLS CUI [1]
C0027765
Psychiatrische Erkrankungen
Description

Psychiatric diseases

Data type

text

Alias
UMLS CUI [1]
C0004936
Bewegungsapparat
Description

Musculoskeletal system

Data type

text

Alias
UMLS CUI [1]
C0026860
Rheumatologie
Description

Rheumatology

Data type

text

Alias
UMLS CUI [1]
C0035452
Phlebologie
Description

Vascular Diseases

Data type

integer

Alias
UMLS CUI [1]
C0042373
Sonstige
Description

Other

Data type

text

Alias
UMLS CUI [1]
C0205394
Operationen
Description

Surgery

Data type

text

Alias
UMLS CUI [1]
C0543467
Sozialanamnese
Description

Social history

Data type

text

Alias
UMLS CUI [1]
C0424945
Medikation
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Allgemeine körperliche Untersuchung
Description

Allgemeine körperliche Untersuchung

Körpergröße
Description

Body Height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Körpergewicht
Description

body weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Allgemeinzustand
Description

General physical condition

Data type

integer

Alias
UMLS CUI [1]
C1142435
Nikotin
Description

Nicotine use

Data type

boolean

Alias
UMLS CUI [1]
C0038586
Alkohol
Description

Alcohol use

Data type

integer

Alias
UMLS CUI [1]
C0001948
Kopf
Description

Head

Data type

text

Alias
UMLS CUI [1]
C0018670
Herz/Thorax
Description

Heart/chest

Data type

text

Alias
UMLS CUI [1]
C0018787
UMLS CUI [2]
C0817096
Lymphknotenstatus
Description

LYMPH NODES

Data type

integer

Alias
UMLS CUI [1]
C0024204
Abdomen
Description

Abdomen

Data type

text

Alias
UMLS CUI [1]
C0000726
Nervensystem/Reflexe
Description

Nervous system/Reflexes

Data type

text

Alias
UMLS CUI [1]
C0027763
UMLS CUI [2]
C0436145
Bewegungsapparat
Description

Musculoskeletal system

Data type

text

Alias
UMLS CUI [1]
C0026860
Gyn
Description

Gynecology

Data type

text

Alias
UMLS CUI [1]
C0018417
Sonstiges
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Arzt
Description

Physician

Data type

text

Alias
UMLS CUI [1]
C0031831
Back to the top of the page

Similar models

Inpatient medical history: Dermatologic specialty, University hospital muenster (UKM)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Demographische Informationen
Patient Name
Item
Name
text
C1299487 (UMLS CUI [1])
Given name
Item
Vorname
text
C1443235 (UMLS CUI [1])
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Item
Geschlecht
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Geschlecht
CL Item
männlich (1)
CL Item
weiblich (2)
Case number
Item
Fall Nummer
integer
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date and time of admission
Item
Aufnahmedatum und Uhrzeit
datetime
C1302393 (UMLS CUI [1,1])
C3854259 (UMLS CUI [1,2])
Admission diagnosis
Item
Einweisungsdiagnose
text
C1628992 (UMLS CUI [1])
Item Group
Spezifische Anamnese und Körperliche Untersuchung
Chief complaint
Item
Hauptbeschwerden
text
C0277786 (UMLS CUI [1])
Current therapy
Item
Bisherige Therapie
text
C0087111 (UMLS CUI [1])
Skin examination
Item
Hautbefund
text
C0436149 (UMLS CUI [1])
Affected area
Item
Befallene Areale (in Grafik einzeichnen)
text
C1879646 (UMLS CUI [1])
Item
Dermographismus
integer
C0343065 (UMLS CUI [1])
Dermographism
Code List
Dermographismus
CL Item
Weiß (1)
CL Item
Rot (2)
CL Item
Urtikariell (3)
Urticaria factitia
Item
Urticaria factitia
boolean
C0152162 (UMLS CUI [1])
Urticaria factitia
Item
Urticaria factitia: Wenn ja, bitte spezifizieren
text
C0152162 (UMLS CUI [1])
Item
Atopische Diathese
integer
C0392707 (UMLS CUI [1])
Atopic Diathesis
Code List
Atopische Diathese
CL Item
Keine (1)
CL Item
Atopisches Ekzem (2)
CL Item
Rhinokonjunktivitis (3)
CL Item
Asthma (4)
Item
Pruritus
integer
C0033774 (UMLS CUI [1])
Pruritus
Code List
Pruritus
CL Item
Keiner (1)
CL Item
Akut <6 Wochen (2)
CL Item
Chronisch >=6Wochen (3)
Mucous Membranes involvement
Item
Schleimhautbeteiligung
boolean
C0026724 (UMLS CUI [1,1])
C0449730 (UMLS CUI [1,2])
Mucous Membranes involvement
Item
Schleimhautbeteiligung: Wenn ja, bitte spezifizieren
text
C0026724 (UMLS CUI [1,1])
C0449730 (UMLS CUI [1,2])
Hypersensitivities
Item
Allergien: Typ 1
boolean
C0020517 (UMLS CUI [1])
Hypersensitivities
Item
Allergien: Typ 1 Wenn ja, bitte spezifizieren
text
C0020517 (UMLS CUI [1])
Contact hypersensitivity
Item
Kontaktallergien
boolean
C0162351 (UMLS CUI [1])
Contact hypersensitivity
Item
Kontaktallergien:Wenn ja, bitte spezifizieren
text
C0162351 (UMLS CUI [1])
Item
AI-Symptome
integer
C0443146 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])
AI-Symptoms
Code List
AI-Symptome
CL Item
Keine (1)
CL Item
Arthralgien (2)
CL Item
Raynaudsymptomatik (3)
CL Item
Sicca-Symptomatik (4)
CL Item
Myalgien (5)
Cutaneous neoplasm
Item
Kutane Neoplasien
boolean
C0037286 (UMLS CUI [1])
Cutaneous neoplasm
Item
Kutane Neoplasien: Wenn ja, bitte spezifizieren
text
C0037286 (UMLS CUI [1])
Dermatologic family medical history
Item
Dermatologische Familienanamnese
boolean
C0241889 (UMLS CUI [1,1])
C0205489 (UMLS CUI [1,2])
Dermatologic family medical history
Item
Dermatologische Familienanamnese: Wenn ja, bitte spezifizieren
text
C0241889 (UMLS CUI [1,1])
C0205489 (UMLS CUI [1,2])
Item Group
Relevante Vorerkrankungen
Cor
Item
Cor
text
C0018787 (UMLS CUI [1])
Pulmo
Item
Pulmo
text
C0024109 (UMLS CUI [1])
Gastrointestinal tract / liver
Item
GIT/Leber:
text
C0017189 (UMLS CUI [1])
C0023884 (UMLS CUI [2])
Genitourinary system/ kidneys
Item
Urogenitaltrakt/Niere
text
C0042066 (UMLS CUI [1])
C0227665 (UMLS CUI [2])
Thyroid Gland
Item
Schilddrüse
text
C0040132 (UMLS CUI [1])
Diabetes mellitus
Item
Diabetes mellitus
text
C0011849 (UMLS CUI [1])
Chronic infections
Item
Chron. Infektionen
text
C0151317 (UMLS CUI [1])
Hematologic diseases
Item
Hämatologische Erkrankungen
text
C0018939 (UMLS CUI [1])
Neoplasm
Item
Tumor
text
C0027651 (UMLS CUI [1])
Neurologic diseases
Item
Neurologische Erkrankungen
text
C0027765 (UMLS CUI [1])
Psychiatric diseases
Item
Psychiatrische Erkrankungen
text
C0004936 (UMLS CUI [1])
Musculoskeletal system
Item
Bewegungsapparat
text
C0026860 (UMLS CUI [1])
Rheumatology
Item
Rheumatologie
text
C0035452 (UMLS CUI [1])
Item
Phlebologie
integer
C0042373 (UMLS CUI [1])
Vascular Diseases
Code List
Phlebologie
CL Item
Keine (1)
CL Item
Sichtbare Varikosis (2)
Other
Item
Sonstige
text
C0205394 (UMLS CUI [1])
Surgery
Item
Operationen
text
C0543467 (UMLS CUI [1])
Social history
Item
Sozialanamnese
text
C0424945 (UMLS CUI [1])
Medication
Item
Medikation
text
C0013227 (UMLS CUI [1])
Item Group
Allgemeine körperliche Untersuchung
Body Height
Item
Körpergröße
integer
C0005890 (UMLS CUI [1])
body weight
Item
Körpergewicht
float
C0005910 (UMLS CUI [1])
Item
Allgemeinzustand
integer
C1142435 (UMLS CUI [1])
General physical condition
Code List
Allgemeinzustand
CL Item
Gut  (1)
CL Item
Reduziert (2)
CL Item
Normalgewichtig  (3)
CL Item
Kachektisch (4)
CL Item
Adipös (5)
Nicotine use
Item
Nikotin
boolean
C0038586 (UMLS CUI [1])
Item
Alkohol
integer
C0001948 (UMLS CUI [1])
Alcohol use
Code List
Alkohol
CL Item
Keine  (1)
CL Item
Wenig Alkoholkonsum (2)
CL Item
Alkoholabusus (3)
Head
Item
Kopf
text
C0018670 (UMLS CUI [1])
Heart/chest
Item
Herz/Thorax
text
C0018787 (UMLS CUI [1])
C0817096 (UMLS CUI [2])
Item
Lymphknotenstatus
integer
C0024204 (UMLS CUI [1])
LYMPH NODES
Code List
Lymphknotenstatus
CL Item
opB (1)
CL Item
path (2)
Abdomen
Item
Abdomen
text
C0000726 (UMLS CUI [1])
Nervous system/Reflexes
Item
Nervensystem/Reflexe
text
C0027763 (UMLS CUI [1])
C0436145 (UMLS CUI [2])
Musculoskeletal system
Item
Bewegungsapparat
text
C0026860 (UMLS CUI [1])
Gynecology
Item
Gyn
text
C0018417 (UMLS CUI [1])
other
Item
Sonstiges
text
C0205394 (UMLS CUI [1])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Physician
Item
Arzt
text
C0031831 (UMLS CUI [1])
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

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