ID

20143

Description

Admission report converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Univ.-Prof. Dr. med. Volker Arolt

Keywords

  1. 1/8/17 1/8/17 -
  2. 1/10/17 1/10/17 -
  3. 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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Psychiatry UKM Admission report

Admission report

  1. StudyEvent: ODM
    1. Admission report
Rest / Sleep
Description

Rest / Sleep

Siesta
Description

Siesta

Data type

integer

Alias
UMLS CUI [1]
C0037313
Sleep disturbances
Description

Sleep disturbances

Data type

boolean

Alias
UMLS CUI [1]
C0037317
Sleep medication
Description

Sleep medication

Data type

boolean

Alias
UMLS CUI [1]
C2054158
Therapeutic Intervention
Description

Therapeutic Intervention

Data type

integer

Alias
UMLS CUI [1]
C0808232
Mobilization
Description

Mobilization

Alias
UMLS CUI-1
C0185112
Permission
Description

Permission to go out

Data type

integer

Alias
UMLS CUI [1]
C0521104
Endurance test
Description

Endurance test

Data type

integer

Alias
UMLS CUI [1]
C0871179
Motor function
Description

Motor function

Data type

integer

Alias
UMLS CUI [1]
C0234130
Personal hygiene
Description

Personal hygiene

Alias
UMLS CUI-1
C0564673
Degree of personal cleanliness
Description

Degree of personal cleanliness

Data type

integer

Alias
UMLS CUI [1]
C0424465
Personal appearance
Description

Personal appearance

Data type

integer

Alias
UMLS CUI [1]
C0233426
Skin
Description

Skin

Data type

integer

Alias
UMLS CUI [1]
C0437750
Hypersensitivity care products
Description

Hypersensitivity care products

Data type

boolean

Alias
UMLS CUI [1,1]
C0020517
UMLS CUI [1,2]
C3897599
Get Dressed With Help
Description

Get Dressed With Help

Data type

boolean

Alias
UMLS CUI [1]
C3639741
Patient's ability to dress self
Description

Patient's ability to dress self

Data type

integer

Alias
UMLS CUI [1]
C0513617
Clothing
Description

Clothing

Data type

integer

Alias
UMLS CUI [1]
C0009072
Eating / Drinking
Description

Eating / Drinking

Nutritional status
Description

Nutritional status

Data type

integer

Alias
UMLS CUI [1]
C0392209
Height
Description

Height

Data type

float

Alias
UMLS CUI [1]
C0005890
Weight
Description

Weight

Data type

integer

Alias
UMLS CUI [1]
C0005910
Diet
Description

Diet

Data type

text

Alias
UMLS CUI [1]
C0012155
Food intake
Description

Food intake

Data type

integer

Alias
UMLS CUI [1]
C0086311
Eating disorder
Description

Eating disorder

Data type

boolean

Alias
UMLS CUI [1]
C0013473
Diet
Description

Diet

Data type

boolean

Alias
UMLS CUI [1]
C0012155
Feeding tube
Description

Feeding tube

Data type

boolean

Alias
UMLS CUI [1]
C0041281
Excretion
Description

Excretion

Ability to use toilet
Description

Ability to use toilet

Data type

boolean

Alias
UMLS CUI [1]
C0562816
Defecation
Description

Defecation

Data type

boolean

Alias
UMLS CUI [1]
C0011135
Encopresis
Description

Encopresis

Data type

integer

Alias
UMLS CUI [1]
C2945606
Menstruation
Description

Menstruation

Data type

integer

Alias
UMLS CUI [1]
C0025344
Enuresis
Description

Enuresis

Data type

integer

Alias
UMLS CUI [1]
C0014394
Respiration
Description

Respiration

Alias
UMLS CUI-1
C0035203
Respiration
Description

Respiration

Data type

boolean

Alias
UMLS CUI [1]
C0035203
Smoker
Description

Smoker

Data type

boolean

Alias
UMLS CUI [1]
C0543414
Cigarettes per day
Description

Cigarettes per day

Data type

integer

Alias
UMLS CUI [1]
C3694146
Alcohol
Description

Alcohol

Data type

boolean

Alias
UMLS CUI [1]
C0001948
Substance abuse
Description

Substance abuse

Data type

boolean

Alias
UMLS CUI [1]
C0038586
Occupation
Description

Occupation

Alias
UMLS CUI-1
C0028811
Daily structure
Description

Daily structure

Data type

integer

Alias
UMLS CUI [1]
C4274625
Child and adolescent psychiatry department
Description

Child and adolescent psychiatry department

Data type

date

Alias
UMLS CUI [1]
C0587495
School
Description

School

Data type

boolean

Alias
UMLS CUI [1]
C0036375
Group therapy
Description

Group therapy

Data type

integer

Alias
UMLS CUI [1]
C0033971
Communication
Description

Communication

Alias
UMLS CUI-1
C0009452
Language
Description

Language

Data type

integer

Alias
UMLS CUI [1]
C1145677
Ability to read
Description

Ability to read

Data type

boolean

Alias
UMLS CUI [1]
C0586740
Ability to read
Description

Ability to write

Data type

boolean

Alias
UMLS CUI [1]
C0584992
Gestures
Description

Gestures

Data type

integer

Alias
UMLS CUI [1]
C0017510
Learning ability
Description

Learning ability

Data type

integer

Alias
UMLS CUI [1]
C0233832
Introversion
Description

Introversion

Data type

integer

Alias
UMLS CUI [1]
C0021924
Mental Processes
Description

Mental Processes

Data type

integer

Alias
UMLS CUI [1]
C0025361
Perception
Description

Perception

Data type

integer

Alias
UMLS CUI [1]
C0030971
Contact
Description

Contact

Data type

integer

Alias
UMLS CUI [1]
C3812666
Ability to take criticism
Description

Ability to take criticism

Data type

integer

Alias
UMLS CUI [1]
C0870379
Physiologic tolerance
Description

Physiologic tolerance

Data type

integer

Alias
UMLS CUI [1]
C0231197
Social Distance
Description

Social Distance

Data type

integer

Alias
UMLS CUI [1]
C0037412
Relegion / Belief
Description

Relegion / Belief

Insight into illness
Description

Insight into illness

Data type

boolean

Alias
UMLS CUI [1]
C3176579
Mood
Description

Mood

Data type

integer

Alias
UMLS CUI [1]
C0026516
Beleifs
Description

Beliefs

Data type

integer

Alias
UMLS CUI [1]
C0004951
Anxiety
Description

Anxiety

Data type

integer

Alias
UMLS CUI [1]
C0003467
Mood swings
Description

Mood swings

Data type

integer

Alias
UMLS CUI [1]
C0085633
Sexuality
Description

Sexuality

Contraception
Description

Contraception

Data type

integer

Alias
UMLS CUI [1]
C0700589
Shame
Description

Shame

Data type

integer

Alias
UMLS CUI [1,1]
C0036938
UMLS CUI [1,2]
C0237676
Treatment of own children
Description

Treatment of own body

Data type

integer

Alias
UMLS CUI [1]
C1522326
Security
Description

Security

Alias
UMLS CUI-1
C0036547
Orientation
Description

Orientation

Data type

integer

Alias
UMLS CUI [1]
C0029266
Pressure ulcer
Description

Pressure ulcer

Data type

boolean

Alias
UMLS CUI [1]
C0558030
Pain
Description

Pain

Data type

boolean

Alias
UMLS CUI [1]
C0030193
At risk for falls
Description

See reverse side for more info if yes

Data type

boolean

Alias
UMLS CUI [1]
C1268740
Risk of falling
Description

Risk of falling

Risk of falling
Description

Risk of falling

Data type

boolean

Alias
UMLS CUI [1]
C1268740
Orientation
Description

Orientation

Data type

integer

Alias
UMLS CUI [1]
C0029266
Excretion
Description

Excretion

Data type

integer

Alias
UMLS CUI [1]
C0504085
History of falls
Description

History of falls

Data type

integer

Alias
UMLS CUI [1]
C0085639
Mobility
Description

Mobility

Data type

integer

Alias
UMLS CUI [1]
C0449580
Visual impairment
Description

Visual impairment

Data type

integer

Alias
UMLS CUI [1]
C3665347
Medicaton
Description

Medication

Data type

integer

Alias
UMLS CUI [1]
C0013227

Similar models

Admission report

  1. StudyEvent: ODM
    1. Admission report
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Rest / Sleep
Item
Siesta
integer
C0037313 (UMLS CUI [1])
Code List
Siesta
CL Item
yes (1)
C1705108 (UMLS CUI-1)
CL Item
no (2)
C1298908 (UMLS CUI-1)
CL Item
Time, if yes: (3)
C0040223 (UMLS CUI-1)
Sleep disturbances
Item
Sleep disturbances
boolean
C0037317 (UMLS CUI [1])
Sleep medication
Item
Sleep medication
boolean
C2054158 (UMLS CUI [1])
Therapeutic Intervention
Item
Therapeutic Intervention
integer
C0808232 (UMLS CUI [1])
Item Group
Mobilization
C0185112 (UMLS CUI-1)
Item
Permission
integer
C0521104 (UMLS CUI [1])
Code List
Permission
CL Item
no permission (1)
C3242263 (UMLS CUI-1)
CL Item
alone (2)
C0679994 (UMLS CUI-1)
CL Item
person accompanying patient (3)
C2079578 (UMLS CUI-1)
Item
Endurance test
integer
C0871179 (UMLS CUI [1])
Code List
Endurance test
CL Item
Time of arrival (1)
C3263562 (UMLS CUI-1)
CL Item
Time of departure  (2)
C4067737 (UMLS CUI-1)
CL Item
Pick-up (3)
Item
Motor function
integer
C0234130 (UMLS CUI [1])
Code List
Motor function
CL Item
Swimmer (1)
C0450068 (UMLS CUI-1)
CL Item
Non swimmer (2)
C0450068 (UMLS CUI-1)
CL Item
Sports (3)
C0038039 (UMLS CUI-1)
CL Item
Hobby (4)
C0019826 (UMLS CUI-1)
Item Group
Personal hygiene
C0564673 (UMLS CUI-1)
Item
Degree of personal cleanliness
integer
C0424465 (UMLS CUI [1])
Code List
Degree of personal cleanliness
CL Item
requires assistance  (1)
C2732873 (UMLS CUI-1)
CL Item
requires request (2)
C1272683 (UMLS CUI-1)
Personal appearance
Item
Personal appearance
integer
C0233426 (UMLS CUI [1])
Skin
Item
Skin
integer
C0437750 (UMLS CUI [1])
Hypersensitivity care products
Item
Hypersensitivity care products
boolean
C0020517 (UMLS CUI [1,1])
C3897599 (UMLS CUI [1,2])
Get Dressed With Help
Item
Get Dressed With Help
boolean
C3639741 (UMLS CUI [1])
Item
Patient's ability to dress self
integer
C0513617 (UMLS CUI [1])
Code List
Patient's ability to dress self
CL Item
requires assistance (1)
C2732873 (UMLS CUI-1)
CL Item
requires request (2)
C1272683 (UMLS CUI-1)
Clothing
Item
Clothing
integer
C0009072 (UMLS CUI [1])
Item Group
Eating / Drinking
Nutritional status
Item
Nutritional status
integer
C0392209 (UMLS CUI [1])
Height
Item
Height
float
C0005890 (UMLS CUI [1])
Weight
Item
Weight
integer
C0005910 (UMLS CUI [1])
Diet
Item
Diet
text
C0012155 (UMLS CUI [1])
Food intake
Item
Food intake
integer
C0086311 (UMLS CUI [1])
Eating disorder
Item
boolean
C0013473 (UMLS CUI [1])
Diet
Item
boolean
C0012155 (UMLS CUI [1])
Feeding tube
Item
boolean
C0041281 (UMLS CUI [1])
Item Group
Excretion
Ability to use toilet
Item
Ability to use toilet
boolean
C0562816 (UMLS CUI [1])
Defecation
Item
Defecation
boolean
C0011135 (UMLS CUI [1])
Encopresis
Item
Encopresis
integer
C2945606 (UMLS CUI [1])
Menstruation
Item
Menstruation
integer
C0025344 (UMLS CUI [1])
Enuresis
Item
Enuresis
integer
C0014394 (UMLS CUI [1])
Item Group
Respiration
C0035203 (UMLS CUI-1)
Respiration
Item
Respiration
boolean
C0035203 (UMLS CUI [1])
Smoker
Item
Smoker
boolean
C0543414 (UMLS CUI [1])
Cigarettes per day
Item
Cigarettes per day
integer
C3694146 (UMLS CUI [1])
Alcohol
Item
Alcohol
boolean
C0001948 (UMLS CUI [1])
Substance abuse
Item
Substance abuse
boolean
C0038586 (UMLS CUI [1])
Item Group
Occupation
C0028811 (UMLS CUI-1)
Daily structure
Item
Daily structure
integer
C4274625 (UMLS CUI [1])
Child and adolescent psychiatry department
Item
Child and adolescent psychiatry department
date
C0587495 (UMLS CUI [1])
School
Item
School
boolean
C0036375 (UMLS CUI [1])
Group therapy
Item
Group therapy
integer
C0033971 (UMLS CUI [1])
Item Group
Communication
C0009452 (UMLS CUI-1)
Language
Item
Language
integer
C1145677 (UMLS CUI [1])
Ability to read
Item
Ability to read
boolean
C0586740 (UMLS CUI [1])
Ability to write
Item
Ability to read
boolean
C0584992 (UMLS CUI [1])
Gestures
Item
Gestures
integer
C0017510 (UMLS CUI [1])
Learning ability
Item
Learning ability
integer
C0233832 (UMLS CUI [1])
Introversion
Item
Introversion
integer
C0021924 (UMLS CUI [1])
Mental Processes
Item
Mental Processes
integer
C0025361 (UMLS CUI [1])
Perception
Item
Perception
integer
C0030971 (UMLS CUI [1])
Contact
Item
Contact
integer
C3812666 (UMLS CUI [1])
Ability to take criticism
Item
Ability to take criticism
integer
C0870379 (UMLS CUI [1])
Physiologic tolerance
Item
Physiologic tolerance
integer
C0231197 (UMLS CUI [1])
Social Distance
Item
Social Distance
integer
C0037412 (UMLS CUI [1])
Item Group
Relegion / Belief
Insight into illness
Item
Insight into illness
boolean
C3176579 (UMLS CUI [1])
Mood
Item
Mood
integer
C0026516 (UMLS CUI [1])
Beliefs
Item
Beleifs
integer
C0004951 (UMLS CUI [1])
Anxiety
Item
Anxiety
integer
C0003467 (UMLS CUI [1])
Mood swings
Item
Mood swings
integer
C0085633 (UMLS CUI [1])
Item Group
Sexuality
Contraception
Item
Contraception
integer
C0700589 (UMLS CUI [1])
Shame
Item
Shame
integer
C0036938 (UMLS CUI [1,1])
C0237676 (UMLS CUI [1,2])
Treatment of own body
Item
Treatment of own children
integer
C1522326 (UMLS CUI [1])
Item Group
Security
C0036547 (UMLS CUI-1)
Item
Orientation
integer
C0029266 (UMLS CUI [1])
Code List
Orientation
CL Item
complete (1)
CL Item
partly (2)
CL Item
no (3)
Pressure ulcer
Item
Pressure ulcer
boolean
C0558030 (UMLS CUI [1])
Pain
Item
Pain
boolean
C0030193 (UMLS CUI [1])
At risk for falls
Item
At risk for falls
boolean
C1268740 (UMLS CUI [1])
Item Group
Risk of falling
Risk of falling
Item
Risk of falling
boolean
C1268740 (UMLS CUI [1])
Item
Orientation
integer
C0029266 (UMLS CUI [1])
Code List
Orientation
CL Item
aid to orientation (1)
CL Item
bell (2)
C1706917 (UMLS CUI-1)
Item
Excretion
integer
C0504085 (UMLS CUI [1])
Code List
Excretion
CL Item
Stool (1)
C0015733 (UMLS CUI-1)
CL Item
medical device (2)
C3177146 (UMLS CUI-1)
CL Item
Bell (3)
C1706917 (UMLS CUI-1)
CL Item
toilet (4)
C1718402 (UMLS CUI-1)
Item
History of falls
integer
C0085639 (UMLS CUI [1])
Code List
History of falls
CL Item
Patient is informed about risk of falls (1)
C1268740 (UMLS CUI-1)
CL Item
Information leaflet handed out to patient (2)
C3697770 (UMLS CUI-1)
Item
Mobility
integer
C0449580 (UMLS CUI [1])
Code List
Mobility
CL Item
Company (1)
C0587717 (UMLS CUI-1)
CL Item
bedridden  (2)
C0425251 (UMLS CUI-1)
C0449580 (UMLS CUI-2)
CL Item
wheel chair (3)
C0043143 (UMLS CUI-1)
CL Item
assistance (4)
C1521721 (UMLS CUI-1)
CL Item
Informed about medical devices (5)
C0025080 (UMLS CUI-1)
Item
Visual impairment
integer
C3665347 (UMLS CUI [1])
Code List
Visual impairment
CL Item
glasses (1)
C0015421 (UMLS CUI-1)
CL Item
access to toilet (2)
C0512933 (UMLS CUI-1)
CL Item
lights on (3)
C0023693 (UMLS CUI-1)
Item
Medicaton
integer
C0013227 (UMLS CUI [1])
Code List
Medicaton
CL Item
Psychotropic Drugs (1)
C0033978 (UMLS CUI-1)
CL Item
Hypnotics and Sedatives (2)
C0020592 (UMLS CUI-1)
CL Item
Antiarrhythmika (3)
C0003195 (UMLS CUI-1)
CL Item
Diuretics (4)
C0012798 (UMLS CUI-1)

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