ID

20591

Description

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form Name: Poliklinik Anamnese

Keywords

  1. 3/5/17 3/5/17 -
Uploaded on

March 5, 2017

DOI

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License

Creative Commons BY-NC 3.0

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Polyclinic Medical History University Hospital Cologne

Polyclinic Medical History University Hospital Cologne

Patientendaten
Description

Patientendaten

Alias
UMLS CUI-1
C2707520
Name:
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Vorname:
Description

Surname

Data type

text

Alias
UMLS CUI [1]
C0421448
Geb.-Datum:
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Fallnummer.:
Description

Case number

Data type

integer

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C0600091
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Uhrzeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Anamnese durch
Description

Investigator

Data type

text

Alias
UMLS CUI [1]
C2826892
Vorstellung
Description

Patient referral

Data type

integer

Alias
UMLS CUI [1]
C0034927
Frauenarzt
Description

Gynecologist

Data type

text

Alias
UMLS CUI [1]
C0237419
Hausarzt
Description

General Practitioners

Data type

text

Alias
UMLS CUI [1]
C0017319
Beruf
Description

Occupations

Data type

text

Alias
UMLS CUI [1]
C0028811
Tel. Pat./ Angehörige
Description

Telephone Number

Data type

text

Alias
UMLS CUI [1]
C1515258
Tel. Pat./ Angehörige Mobil:
Description

Telephone Number

Data type

text

Alias
UMLS CUI [1]
C1515258
Vitalzeichen
Description

Vitalzeichen

Alias
UMLS CUI-1
C0518766
RR systolisch
Description

Systolic blood pressure

Data type

float

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
RR diastolisch
Description

Diastolic blood pressure

Data type

float

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0428883
mmHg
Pulse
Description

Heart rate

Data type

float

Measurement units
  • .min
Alias
UMLS CUI [1]
C0018810
.min
Temp
Description

Body temperature

Data type

float

Measurement units
  • C.
Alias
UMLS CUI [1]
C0886414
C.
betaHCG
Description

hcg

Data type

float

Alias
UMLS CUI [1]
C0428402
U-Stix
Description

Urine Testing

Data type

integer

Alias
UMLS CUI [1,1]
C0200354
UMLS CUI [1,2]
C0456984
Sonstiges
Description

Specification Of "Other"

Data type

text

Alias
UMLS CUI [1]
C1521902
Anamnese
Description

Anamnese

Alias
UMLS CUI-1
C0262926
Familienanamnese
Description

Family History

Data type

boolean

Alias
UMLS CUI [1]
C0241889
Familienanamnese
Description

Specification

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C2348235
Vorerkrankungen
Description

Comorbidity

Data type

boolean

Alias
UMLS CUI [1]
C0009488
Vorerkrankungen
Description

Specification

Data type

text

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C2348235
Medikamente (Substanz, Dosierung)
Description

Medikamente (Substanz, Dosierung)

Alias
UMLS CUI-1
C0013227
Präparat
Description

Pharmaceutical Preparations

Data type

text

Alias
UMLS CUI [1]
C0013227
Dosis
Description

dose

Data type

text

Alias
UMLS CUI [1]
C3174092
Operationen
Description

Operationen

Alias
UMLS CUI-1
C0543467
Jahr
Description

Year

Data type

partialDate

Alias
UMLS CUI [1]
C0439234
Operation
Description

Surgical Procedure

Data type

text

Alias
UMLS CUI [1]
C0543467
Schwangerschaft
Description

Schwangerschaft

Alias
UMLS CUI-1
C0032961
Schwangerschaft
Description

Pregnancy

Data type

boolean

Alias
UMLS CUI [1]
C0032961
akt. Dat
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
letzte Periode
Description

Menstruation

Data type

date

Alias
UMLS CUI [1]
C0025344
akt. Dat - letzte Periode = SSW
Description

Weeks Pregnant

Data type

float

Measurement units
  • Woche
Alias
UMLS CUI [1]
C1135241
Woche
letzte Periode/Dat. = errechnetes Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Gravida
Description

Pregnancy

Data type

float

Alias
UMLS CUI [1]
C0032961
Para
Description

Births

Data type

float

Alias
UMLS CUI [1]
C1148523
Schwangerschaften
Description

Schwangerschaften

Alias
UMLS CUI-1
C0032961
Jahr
Description

Year

Data type

partialDate

Alias
UMLS CUI [1]
C0439234
Modus
Description

Type Of Birth

Data type

text

Alias
UMLS CUI [1]
C2239272
Besonderheiten
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Anamnese
Description

Anamnese

Alias
UMLS CUI-1
C0262926
Größe
Description

Body height

Data type

float

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

body weight

Data type

float

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

Blood group

Data type

text

Alias
UMLS CUI [1]
C0005810
Rh
Description

Rhesus

Data type

text

Alias
UMLS CUI [1]
C0427641
Nikotin
Description

Smoking Status

Data type

boolean

Alias
UMLS CUI [1]
C1519386
Bemerkung
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Alkohol
Description

Alcohol

Data type

boolean

Alias
UMLS CUI [1]
C0001948
Bemerkung
Description

comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Kontrazeption
Description

Contraceptive Methods

Data type

text

Alias
UMLS CUI [1]
C0700589
Krebsvorsorge
Description

Cancer Screening

Data type

text

Alias
UMLS CUI [1]
C0278974
Mammographie
Description

Mammography

Data type

text

Alias
UMLS CUI [1]
C0024671
Allergien
Description

Allergy

Data type

boolean

Alias
UMLS CUI [1]
C0020517
Bemerkung
Description

comment

Data type

text

Alias
UMLS CUI [1]
C0947611
LP
Description

Lumbal puncture

Data type

text

Alias
UMLS CUI [1]
C0553794
Zyklus
Description

Menstrual cycle

Data type

text

Alias
UMLS CUI [1]
C0025329
Menopause
Description

Menopause

Data type

boolean

Alias
UMLS CUI [1]
C0455962
Seit wann?
Description

Date Of Beginning Of Menopause

Data type

date

Alias
UMLS CUI [1]
C0011008
Miktion
Description

Urination

Data type

text

Alias
UMLS CUI [1]
C0042034
Stuhlgang
Description

Defecation

Data type

text

Alias
UMLS CUI [1]
C0011135
Blutung-/Thromboseneigung
Description

Bleeding Risk

Data type

boolean

Alias
UMLS CUI [1]
C3251812
Bemerkung
Description

comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Körperliche Untersuchung
Description

Körperliche Untersuchung

Alias
UMLS CUI-1
C0031809
Äußeres Genital
Description

External Genitalia

Data type

text

Alias
UMLS CUI [1]
C0227605
Speculum
Description

Speculum

Data type

text

Alias
UMLS CUI [1]
C0037816
pH
Description

pH

Data type

text

Alias
UMLS CUI [1]
C0042044
Nativ
Description

Nativ

Data type

text

Abstrich
Description

Smear Test

Data type

boolean

Alias
UMLS CUI [1]
C0444186
Bemerkung
Description

comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Tastbefund
Description

Palpation

Data type

text

Alias
UMLS CUI [1]
C0030247
Sonographie
Description

Sonographie

Alias
UMLS CUI-1
C0041618
Uterus
Description

Uterus

Data type

text

Alias
UMLS CUI [1]
C0042149
Ovar// Adnexe rechts
Description

Ovary right

Data type

text

Alias
UMLS CUI [1,1]
C0029939
UMLS CUI [1,2]
C0205090
Ovar// Adnexe links
Description

Ovary left

Data type

text

Alias
UMLS CUI [1,1]
C0029939
UMLS CUI [1,2]
C0205091
Douglasraum
Description

Extracavatio recto

Data type

text

Alias
UMLS CUI [1]
C0013075
Sono
Description

Ultrasonography

Data type

text

Alias
UMLS CUI [1]
C0041618
Mammae
Description

Breast

Data type

text

Alias
UMLS CUI [1]
C0006141
sonstiges
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Diagnosen
Description

Diagnosen

Alias
UMLS CUI-1
C0011900
Klinische Diagnose
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Procedere
Description

Procedere

Alias
UMLS CUI-1
C0087111
Procedere
Description

Procedure

Data type

text

Alias
UMLS CUI [1]
C0087111
Unterschriften
Description

Unterschriften

Alias
UMLS CUI-1
C1519316
Name/Unterschrift des behandelndes Arztes
Description

Signature Of Attending Physician

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C2361125
Name/Unterschrift des behandelnden Facharztes
Description

Signature Of Treating Physician

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C1710470

Similar models

Polyclinic Medical History University Hospital Cologne

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patientendaten
C2707520 (UMLS CUI-1)
Name
Item
Name:
text
C0027365 (UMLS CUI [1])
Surname
Item
Vorname:
text
C0421448 (UMLS CUI [1])
Date of birth
Item
Geb.-Datum:
date
C0421451 (UMLS CUI [1])
Case number
Item
Fallnummer.:
integer
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Investigator
Item
Anamnese durch
text
C2826892 (UMLS CUI [1])
Item
Vorstellung
integer
C0034927 (UMLS CUI [1])
Code List
Vorstellung
CL Item
Erstvorstellung (1)
CL Item
Wiedervorstellung (2)
Gynecologist
Item
Frauenarzt
text
C0237419 (UMLS CUI [1])
General Practitioners
Item
Hausarzt
text
C0017319 (UMLS CUI [1])
Occupations
Item
Beruf
text
C0028811 (UMLS CUI [1])
Telephone Number
Item
Tel. Pat./ Angehörige
text
C1515258 (UMLS CUI [1])
Telephone Number
Item
Tel. Pat./ Angehörige Mobil:
text
C1515258 (UMLS CUI [1])
Item Group
Vitalzeichen
C0518766 (UMLS CUI-1)
Systolic blood pressure
Item
RR systolisch
float
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
RR diastolisch
float
C0428883 (UMLS CUI [1])
Heart rate
Item
Pulse
float
C0018810 (UMLS CUI [1])
Body temperature
Item
Temp
float
C0886414 (UMLS CUI [1])
hcg
Item
betaHCG
float
C0428402 (UMLS CUI [1])
Item
U-Stix
integer
C0200354 (UMLS CUI [1,1])
C0456984 (UMLS CUI [1,2])
Code List
U-Stix
CL Item
unauffällig (1)
CL Item
auffällig (2)
CL Item
Sonstiges (3)
Specification Of "Other"
Item
Sonstiges
text
C1521902 (UMLS CUI [1])
Item Group
Anamnese
C0262926 (UMLS CUI-1)
Family History
Item
Familienanamnese
boolean
C0241889 (UMLS CUI [1])
Specification
Item
Familienanamnese
text
C0241889 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Comorbidity
Item
Vorerkrankungen
boolean
C0009488 (UMLS CUI [1])
Specification
Item
Vorerkrankungen
text
C0009488 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Item Group
Medikamente (Substanz, Dosierung)
C0013227 (UMLS CUI-1)
Pharmaceutical Preparations
Item
Präparat
text
C0013227 (UMLS CUI [1])
dose
Item
Dosis
text
C3174092 (UMLS CUI [1])
Item Group
Operationen
C0543467 (UMLS CUI-1)
Year
Item
Jahr
partialDate
C0439234 (UMLS CUI [1])
Surgical Procedure
Item
Operation
text
C0543467 (UMLS CUI [1])
Item Group
Schwangerschaft
C0032961 (UMLS CUI-1)
Pregnancy
Item
Schwangerschaft
boolean
C0032961 (UMLS CUI [1])
date
Item
akt. Dat
date
C0011008 (UMLS CUI [1])
Menstruation
Item
letzte Periode
date
C0025344 (UMLS CUI [1])
Weeks Pregnant
Item
akt. Dat - letzte Periode = SSW
float
C1135241 (UMLS CUI [1])
Date of birth
Item
letzte Periode/Dat. = errechnetes Geburtsdatum
date
C0421451 (UMLS CUI [1])
Pregnancy
Item
Gravida
float
C0032961 (UMLS CUI [1])
Births
Item
Para
float
C1148523 (UMLS CUI [1])
Item Group
Schwangerschaften
C0032961 (UMLS CUI-1)
Year
Item
Jahr
partialDate
C0439234 (UMLS CUI [1])
Type Of Birth
Item
Modus
text
C2239272 (UMLS CUI [1])
Comment
Item
Besonderheiten
text
C0947611 (UMLS CUI [1])
Item Group
Anamnese
C0262926 (UMLS CUI-1)
Body height
Item
Größe
float
C0005890 (UMLS CUI [1])
body weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Blood group
Item
Blutgruppe
text
C0005810 (UMLS CUI [1])
Rhesus
Item
Rh
text
C0427641 (UMLS CUI [1])
Smoking Status
Item
Nikotin
boolean
C1519386 (UMLS CUI [1])
Comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Contraceptive Methods
Item
Kontrazeption
text
C0700589 (UMLS CUI [1])
Cancer Screening
Item
Krebsvorsorge
text
C0278974 (UMLS CUI [1])
Mammography
Item
Mammographie
text
C0024671 (UMLS CUI [1])
Allergy
Item
Allergien
boolean
C0020517 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Lumbal puncture
Item
LP
text
C0553794 (UMLS CUI [1])
Menstrual cycle
Item
Zyklus
text
C0025329 (UMLS CUI [1])
Menopause
Item
Menopause
boolean
C0455962 (UMLS CUI [1])
Date Of Beginning Of Menopause
Item
Seit wann?
date
C0011008 (UMLS CUI [1])
Urination
Item
Miktion
text
C0042034 (UMLS CUI [1])
Defecation
Item
Stuhlgang
text
C0011135 (UMLS CUI [1])
Bleeding Risk
Item
Blutung-/Thromboseneigung
boolean
C3251812 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Item Group
Körperliche Untersuchung
C0031809 (UMLS CUI-1)
External Genitalia
Item
Äußeres Genital
text
C0227605 (UMLS CUI [1])
Speculum
Item
Speculum
text
C0037816 (UMLS CUI [1])
pH
Item
pH
text
C0042044 (UMLS CUI [1])
Nativ
Item
Nativ
text
Smear Test
Item
Abstrich
boolean
C0444186 (UMLS CUI [1])
comment
Item
Bemerkung
text
C0947611 (UMLS CUI [1])
Palpation
Item
Tastbefund
text
C0030247 (UMLS CUI [1])
Item Group
Sonographie
C0041618 (UMLS CUI-1)
Uterus
Item
Uterus
text
C0042149 (UMLS CUI [1])
Ovary right
Item
Ovar// Adnexe rechts
text
C0029939 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Ovary left
Item
Ovar// Adnexe links
text
C0029939 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Extracavatio recto
Item
Douglasraum
text
C0013075 (UMLS CUI [1])
Ultrasonography
Item
Sono
text
C0041618 (UMLS CUI [1])
Breast
Item
Mammae
text
C0006141 (UMLS CUI [1])
Comment
Item
sonstiges
text
C0947611 (UMLS CUI [1])
Item Group
Diagnosen
C0011900 (UMLS CUI-1)
Diagnosis
Item
Klinische Diagnose
text
C0011900 (UMLS CUI [1])
Item Group
Procedere
C0087111 (UMLS CUI-1)
Procedure
Item
Procedere
text
C0087111 (UMLS CUI [1])
Item Group
Unterschriften
C1519316 (UMLS CUI-1)
Signature Of Attending Physician
Item
Name/Unterschrift des behandelndes Arztes
text
C1519316 (UMLS CUI [1,1])
C2361125 (UMLS CUI [1,2])
Signature Of Treating Physician
Item
Name/Unterschrift des behandelnden Facharztes
text
C1519316 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])

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