ID

20136

Description

Medical History Form converted to ODM format. Routine documentation of university hospital muenster. Publication granted by Prof. Dr. Dr. Kleinheinz

Keywords

  1. 11/30/16 11/30/16 -
  2. 2/8/17 2/8/17 -
Uploaded on

February 8, 2017

DOI

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License

Creative Commons BY-NC 3.0

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Oral and maxillofacial surgery medical history form UKM

Medical history

  1. StudyEvent: ODM
    1. Medical history
Patient demographics
Description

Patient demographics

Patient name
Description

Patient name

Data type

integer

Alias
UMLS CUI [1]
C1299487
Diagnosis
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Patient date of birth
Description

Patient date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Family history
Description

Family history

Neoplasia
Description

Neoplasia

Data type

integer

Alias
UMLS CUI [1]
C1882062
Cleft Palate
Description

Cleft Palate

Data type

integer

Alias
UMLS CUI [1]
C0008925
Other disease
Description

Other disease

Data type

integer

Alias
UMLS CUI [1]
C2359476
General medical history
Description

General medical history

Medical history
Description

Medical history

Data type

integer

Alias
UMLS CUI [1]
C0262926
Occupation
Description

Occupation

Data type

integer

Alias
UMLS CUI [1]
C0028811
Medication
Description

Medication

Data type

integer

Alias
UMLS CUI [1]
C0013227
Special medical history
Description

Special medical history

Medical history
Description

Medical history

Data type

integer

Alias
UMLS CUI [1]
C1704706
Medical report
Description

Medical report

General condition
Description

General condition

Data type

integer

Alias
UMLS CUI [1]
C1142435
Skin
Description

Skin

Data type

integer

Alias
UMLS CUI [1]
C1123023
Lymph nodes
Description

Lymph nodes

Data type

integer

Alias
UMLS CUI [1]
C0024204
Weight
Description

Weight

Data type

integer

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

Diabetes

Data type

integer

Alias
UMLS CUI [1]
C0011849
Bleeding tendency
Description

Bleeding tendency

Data type

integer

Alias
UMLS CUI [1]
C1458140
Thrombosis
Description

Thrombosis

Data type

integer

Alias
UMLS CUI [1]
C0040053
Allergies
Description

Allergies

Data type

integer

Alias
UMLS CUI [1]
C0020517
Dyspnoe
Description

Dyspnoe

Data type

integer

Alias
UMLS CUI [1]
C0013404
Cyanosis
Description

Cyanosis

Data type

integer

Alias
UMLS CUI [1]
C0010520
Edema
Description

Edema

Data type

integer

Alias
UMLS CUI [1]
C0013604
Nocturia
Description

Nocturia

Data type

integer

Alias
UMLS CUI [1]
C0028734
Substance abuse
Description

Substance abuse

Data type

integer

Alias
UMLS CUI [1]
C0038586
Alcohol
Description

Alcohol

Data type

integer

Alias
UMLS CUI [1]
C0001948
Nicotin
Description

Nicotin

Data type

integer

Alias
UMLS CUI [1]
C0028040
Chest
Description

Chest

Alias
UMLS CUI-1
C0817096
Margin of lung
Description

Margin of lung

Data type

integer

Alias
UMLS CUI [1]
C1282028
Ppercussion of lung
Description

Ppercussion of lung

Data type

integer

Alias
UMLS CUI [1]
C1291006
Respiratory Sounds
Description

Respiratory Sounds

Data type

integer

Alias
UMLS CUI [1]
C0035234
Heart sounds
Description

Heart sounds

Data type

integer

Alias
UMLS CUI [1]
C0018820
Heartbeat
Description

Heartbeat

Data type

integer

Alias
UMLS CUI [1]
C0425583
RR
Description

RR

Data type

integer

Alias
UMLS CUI [1]
C0005823
Pulse
Description

Pulse

Data type

integer

Alias
UMLS CUI [1]
C0232117
Mammae
Description

Mammae

Data type

integer

Alias
UMLS CUI [1]
C0006141
Abdomen
Description

Abdomen

Alias
UMLS CUI-1
C0000726
Liver
Description

Liver

Data type

integer

Alias
UMLS CUI [1]
C0023884
Spleen
Description

Spleen

Data type

integer

Alias
UMLS CUI [1]
C0037993
Pain pressure
Description

Pain pressure

Data type

integer

Alias
UMLS CUI [1]
C3647129
Hernia
Description

Hernia

Data type

integer

Alias
UMLS CUI [1]
C0019270
Scar Tissue
Description

Scar Tissue

Data type

integer

Alias
UMLS CUI [1]
C0241158
Extremities
Description

Extremities

Extremities
Description

Extremities

Data type

integer

Alias
UMLS CUI [1]
C0015385
Nervous system
Description

Nervous system

Nervous system
Description

Nervous system

Data type

integer

Alias
UMLS CUI [1]
C0027763
Spinal column
Description

Spinal column

Entire vertebral column
Description

Entire vertebral column

Data type

integer

Alias
UMLS CUI [1]
C1267072
Special medical report
Description

Special medical report

Extraoral
Description

Extraoral

Data type

integer

Alias
UMLS CUI [1]
C0442089
Ocular motility observations
Description

Ocular motility observations

Data type

integer

Alias
UMLS CUI [1]
C0549100
Diplopia
Description

Diplopia

Data type

integer

Alias
UMLS CUI [1]
C0012569
Trigeminal nerve structure
Description

Trigeminal nerve structure

Data type

integer

Alias
UMLS CUI [1]
C0040996
Facial nerve structure
Description

Facial nerve structure

Data type

integer

Alias
UMLS CUI [1]
C0015462
Lymph nodes
Description

Lymph nodes

Data type

integer

Alias
UMLS CUI [1]
C0024204
Mouth opening
Description

Mouth opening

Data type

integer

Measurement units
  • mm
Alias
UMLS CUI [1]
C0226895
mm
Pain in head
Description

Pain in head

Data type

integer

Alias
UMLS CUI [1]
C2370967
Mucosa
Description

Mucosa

Data type

integer

Alias
UMLS CUI [1]
C0026724
Tongue
Description

Tongue

Data type

integer

Alias
UMLS CUI [1]
C0040408
Waldeyer's ring
Description

Waldeyer's ring

Data type

integer

Alias
UMLS CUI [1]
C0459892
Dental Calculus
Description

Dental Calculus

Data type

integer

Alias
UMLS CUI [1]
C0011330
Periodontal Diseases
Description

Periodontal Diseases

Data type

integer

Alias
UMLS CUI [1]
C0031090
X-rays results
Description

X-rays results

X-rays results
Description

X-rays results

Data type

integer

Alias
UMLS CUI [1]
C0850567
Footer module
Description

Footer module

Date
Description

Date

Data type

integer

Alias
UMLS CUI [1]
C0011008
Signature
Description

Signature

Data type

integer

Alias
UMLS CUI [1]
C1519316

Similar models

Medical history

  1. StudyEvent: ODM
    1. Medical history
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient demographics
Patient name
Item
Patient name
integer
C1299487 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Patient date of birth
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Item Group
Family history
Neoplasia
Item
Neoplasia
integer
C1882062 (UMLS CUI [1])
Cleft Palate
Item
Cleft Palate
integer
C0008925 (UMLS CUI [1])
Other disease
Item
Other disease
integer
C2359476 (UMLS CUI [1])
Item Group
General medical history
Medical history
Item
Medical history
integer
C0262926 (UMLS CUI [1])
Occupation
Item
Occupation
integer
C0028811 (UMLS CUI [1])
Medication
Item
Medication
integer
C0013227 (UMLS CUI [1])
Item Group
Special medical history
Medical history
Item
Medical history
integer
C1704706 (UMLS CUI [1])
Item Group
Medical report
General condition
Item
General condition
integer
C1142435 (UMLS CUI [1])
Skin
Item
Skin
integer
C1123023 (UMLS CUI [1])
Lymph nodes
Item
Lymph nodes
integer
C0024204 (UMLS CUI [1])
Weight
Item
Weight
integer
C0005910 (UMLS CUI [1])
Diabetes
Item
Diabetes
integer
C0011849 (UMLS CUI [1])
Bleeding tendency
Item
Bleeding tendency
integer
C1458140 (UMLS CUI [1])
Thrombosis
Item
Thrombosis
integer
C0040053 (UMLS CUI [1])
Allergies
Item
Allergies
integer
C0020517 (UMLS CUI [1])
Dyspnoe
Item
Dyspnoe
integer
C0013404 (UMLS CUI [1])
Cyanosis
Item
Cyanosis
integer
C0010520 (UMLS CUI [1])
Edema
Item
Edema
integer
C0013604 (UMLS CUI [1])
Nocturia
Item
Nocturia
integer
C0028734 (UMLS CUI [1])
Substance abuse
Item
Substance abuse
integer
C0038586 (UMLS CUI [1])
Alcohol
Item
Alcohol
integer
C0001948 (UMLS CUI [1])
Nicotin
Item
Nicotin
integer
C0028040 (UMLS CUI [1])
Item Group
Chest
C0817096 (UMLS CUI-1)
Margin of lung
Item
Margin of lung
integer
C1282028 (UMLS CUI [1])
Ppercussion of lung
Item
Ppercussion of lung
integer
C1291006 (UMLS CUI [1])
Respiratory Sounds
Item
Respiratory Sounds
integer
C0035234 (UMLS CUI [1])
Heart sounds
Item
Heart sounds
integer
C0018820 (UMLS CUI [1])
Heartbeat
Item
Heartbeat
integer
C0425583 (UMLS CUI [1])
RR
Item
RR
integer
C0005823 (UMLS CUI [1])
Pulse
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Mammae
Item
Mammae
integer
C0006141 (UMLS CUI [1])
Item Group
Abdomen
C0000726 (UMLS CUI-1)
Liver
Item
Liver
integer
C0023884 (UMLS CUI [1])
Spleen
Item
Spleen
integer
C0037993 (UMLS CUI [1])
Pain pressure
Item
Pain pressure
integer
C3647129 (UMLS CUI [1])
Hernia
Item
Hernia
integer
C0019270 (UMLS CUI [1])
Scar Tissue
Item
Scar Tissue
integer
C0241158 (UMLS CUI [1])
Item Group
Extremities
Extremities
Item
Extremities
integer
C0015385 (UMLS CUI [1])
Item Group
Nervous system
Nervous system
Item
Nervous system
integer
C0027763 (UMLS CUI [1])
Item Group
Spinal column
Entire vertebral column
Item
Entire vertebral column
integer
C1267072 (UMLS CUI [1])
Item Group
Special medical report
Extraoral
Item
Extraoral
integer
C0442089 (UMLS CUI [1])
Ocular motility observations
Item
Ocular motility observations
integer
C0549100 (UMLS CUI [1])
Diplopia
Item
Diplopia
integer
C0012569 (UMLS CUI [1])
Trigeminal nerve structure
Item
Trigeminal nerve structure
integer
C0040996 (UMLS CUI [1])
Facial nerve structure
Item
Facial nerve structure
integer
C0015462 (UMLS CUI [1])
Lymph nodes
Item
Lymph nodes
integer
C0024204 (UMLS CUI [1])
Mouth opening
Item
Mouth opening
integer
C0226895 (UMLS CUI [1])
Item
Pain in head
integer
C2370967 (UMLS CUI [1])
Code List
Pain in head
CL Item
Temporomandibular joint lateral (1)
C0039493 (UMLS CUI-1)
CL Item
Temporomandibular joint posterior (2)
C0039493 (UMLS CUI-1)
CL Item
Temporalis muscle (3)
C0039487 (UMLS CUI-1)
CL Item
Masseter muscle  (4)
C0024876 (UMLS CUI-1)
CL Item
Suboccipital muscle (5)
C0448352 (UMLS CUI-1)
CL Item
Sternocleidomastoid muscle (6)
C0224153 (UMLS CUI-1)
CL Item
M. digastricus (7)
C0224155 (UMLS CUI-1)
CL Item
M. pterygoideus med. (8)
C0224146 (UMLS CUI-1)
CL Item
M. pterygoideus lat. (9)
C0224145 (UMLS CUI-1)
Mucosa
Item
Mucosa
integer
C0026724 (UMLS CUI [1])
Tongue
Item
Tongue
integer
C0040408 (UMLS CUI [1])
Waldeyer's ring
Item
Waldeyer's ring
integer
C0459892 (UMLS CUI [1])
Dental Calculus
Item
Dental Calculus
integer
C0011330 (UMLS CUI [1])
Periodontal Diseases
Item
Periodontal Diseases
integer
C0031090 (UMLS CUI [1])
Item Group
X-rays results
X-rays results
Item
X-rays results
integer
C0850567 (UMLS CUI [1])
Item Group
Footer module
Date
Item
Date
integer
C0011008 (UMLS CUI [1])
Signature
Item
Signature
integer
C1519316 (UMLS CUI [1])

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