ID

21243

Description

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: Anamnese_Standard

Keywords

Versions (1)
  1. 4/16/17 4/16/17 -
Uploaded on

April 16, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Medical history report (standard), University Hospital Cologne

German

Medical history report (standard), University Hospital Cologne

1 forms  
Anamnese (Standard)
Description

Anamnese (Standard)

Alias
UMLS CUI-1
C0262926
Patient
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Anamnese erhoben von
Description

Medical history taken by

Data type

text

Measurement units
  • Name
Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C3476341
Name
Anamnese erhoben am
Description

Medical history taken on

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0011008
dd.mm.yyyy
Erhebungsmodus
Description

Medical history taking type

Data type

integer

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Falls Fremdanamnese,...
Description

If third-party anamnesis,...

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C1303082
Aktuelle Anamnese
Description

Current anamnesis

Data type

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0521116
Vorerkrankungen
Description

Pre-existing conditions

Data type

boolean

Alias
UMLS CUI [1]
C0521987
Operationen
Description

Surgical procedures

Data type

boolean

Alias
UMLS CUI [1]
C0543467
Medikamente
Description

Medication

Data type

boolean

Alias
UMLS CUI [1]
C0013227
Allergien
Description

Allergies

Data type

boolean

Alias
UMLS CUI [1]
C0020517
Risikofaktoren
Description

Risikofaktoren

Alias
UMLS CUI-1
C0035648
Alkohol
Description

Use of alcohol

Data type

boolean

Alias
UMLS CUI [1]
C0001948
Nikotin
Description

Tobacco use

Data type

boolean

Alias
UMLS CUI [1]
C0543414
Sonstiges
Description

Other risk factors

Data type

boolean

Alias
UMLS CUI [1,1]
C0035648
UMLS CUI [1,2]
C0205394
Kinderkrankheiten
Description

Kinderkrankheiten

Alias
UMLS CUI-1
C0489532
Scharlach
Description

Scarlet fever

Data type

boolean

Alias
UMLS CUI [1]
C0036285
Masern
Description

Measles

Data type

boolean

Alias
UMLS CUI [1]
C0025007
Diphtherie
Description

Diphtheria

Data type

boolean

Alias
UMLS CUI [1]
C0012546
Röteln
Description

Rubella

Data type

boolean

Alias
UMLS CUI [1]
C0035920
Varizellen
Description

Varicella

Data type

boolean

Alias
UMLS CUI [1]
C0740380
Mumps
Description

Mumps

Data type

boolean

Alias
UMLS CUI [1]
C0026780
Pertussis
Description

Pertussis

Data type

boolean

Alias
UMLS CUI [1]
C0043167
Sonstiges
Description

Other childhood diseases

Data type

boolean

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0489532
Familienkrankheiten
Description

Familienkrankheiten

Alias
UMLS CUI-1
C0344339
Mutter
Description

Mother

Data type

text

Alias
UMLS CUI [1,1]
C0026591
UMLS CUI [1,2]
C0344339
Vater
Description

Father

Data type

text

Alias
UMLS CUI [1,1]
C0015671
UMLS CUI [1,2]
C0344339
Sonstige
Description

Other

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0344339
Soziale Anamnese
Description

Soziale Anamnese

Alias
UMLS CUI-1
C0424945
Beruf
Description

Occupation

Data type

text

Alias
UMLS CUI [1]
C0028811
Familienstand
Description

Marital status

Data type

integer

Alias
UMLS CUI [1]
C0024819
Anzahl der Kinder
Description

Number of children

Data type

integer

Alias
UMLS CUI [1]
C2229974
Häusliche Situation
Description

Home environment

Data type

integer

Alias
UMLS CUI [1]
C0442519
Gynäkologische Anamnese
Description

Gynäkologische Anamnese

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0205480
1. Regelblutung
Description

Age at menarche

Data type

integer

Measurement units
  • Alter
Alias
UMLS CUI [1]
C1314691
Alter
Letzte Regelblutung
Description

Age at menopause

Data type

integer

Measurement units
  • Alter
Alias
UMLS CUI [1]
C1629609
Alter
Regelblutung
Description

Menstruation type

Data type

integer

Alias
UMLS CUI [1,1]
C0025344
UMLS CUI [1,2]
C0332307
Geburten
Description

Number of births

Data type

integer

Alias
UMLS CUI [1]
C3172256
Fehlgeburten
Description

Number of miscarriages

Data type

integer

Alias
UMLS CUI [1]
C0429916
Vegetative Anamnese
Description

Vegetative Anamnese

Alias
UMLS CUI-1
C0489633
UMLS CUI-2
C0262926
Größe
Description

Body height

Data type

float

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

Body weight

Data type

float

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

Body weight changes

Data type

integer

Alias
UMLS CUI [1]
C0005911
Stuhlgang
Description

Defecation

Data type

integer

Alias
UMLS CUI [1]
C0011135
Miktion
Description

Urination

Data type

integer

Alias
UMLS CUI [1]
C0042034
Nykturie
Description

Nocturia

Data type

boolean

Alias
UMLS CUI [1]
C0028734
Nachtschweiß
Description

Night sweats

Data type

boolean

Alias
UMLS CUI [1]
C0028081
Fieber
Description

Fever

Data type

boolean

Alias
UMLS CUI [1]
C0015967
Luftnot
Description

Dyspnea

Data type

boolean

Alias
UMLS CUI [1]
C0013404
Ödeme
Description

Edema

Data type

boolean

Alias
UMLS CUI [1]
C0013604
Husten
Description

Coughing

Data type

boolean

Alias
UMLS CUI [1]
C0010200
Auswurf
Description

Sputum

Data type

boolean

Alias
UMLS CUI [1]
C0038056
Appetit
Description

Desire for food

Data type

integer

Alias
UMLS CUI [1]
C0003618
Durst
Description

Thirst

Data type

float

Measurement units
  • L/d
Alias
UMLS CUI [1]
C0039971
L/d
Schlaf
Description

Sleep

Data type

integer

Alias
UMLS CUI [1]
C0037313
Sonstiges
Description

Other

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0489633
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Similar models

Medical history report (standard), University Hospital Cologne

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Anamnese (Standard)
C0262926 (UMLS CUI-1)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Medical history taken by
Item
Anamnese erhoben von
text
C0025084 (UMLS CUI [1,1])
C3476341 (UMLS CUI [1,2])
Medical history taken on
Item
Anamnese erhoben am
date
C0025084 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Erhebungsmodus
integer
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Medical history taking type
Code List
Erhebungsmodus
CL Item
Eigenanamnese (1)
CL Item
Fremdanamnese (2)
CL Item
sonstiges (3)
Item
Falls Fremdanamnese,...
text
C0025084 (UMLS CUI [1,1])
C1303082 (UMLS CUI [1,2])
If third-party anamnesis,...
Code List
Falls Fremdanamnese,...
CL Item
erhoben zusammen mit Mutter (1)
CL Item
erhoben zusammen mit Vater (2)
CL Item
sonstiges (3)
Current anamnesis
Item
Aktuelle Anamnese
text
C0262926 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Pre-existing conditions
Item
Vorerkrankungen
boolean
C0521987 (UMLS CUI [1])
Surgical procedures
Item
Operationen
boolean
C0543467 (UMLS CUI [1])
Medication
Item
Medikamente
boolean
C0013227 (UMLS CUI [1])
Allergies
Item
Allergien
boolean
C0020517 (UMLS CUI [1])
Item Group
Risikofaktoren
C0035648 (UMLS CUI-1)
Use of alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
Tobacco use
Item
Nikotin
boolean
C0543414 (UMLS CUI [1])
Other risk factors
Item
Sonstiges
boolean
C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Kinderkrankheiten
C0489532 (UMLS CUI-1)
Scarlet fever
Item
Scharlach
boolean
C0036285 (UMLS CUI [1])
Measles
Item
Masern
boolean
C0025007 (UMLS CUI [1])
Diphtheria
Item
Diphtherie
boolean
C0012546 (UMLS CUI [1])
Rubella
Item
Röteln
boolean
C0035920 (UMLS CUI [1])
Varicella
Item
Varizellen
boolean
C0740380 (UMLS CUI [1])
Mumps
Item
Mumps
boolean
C0026780 (UMLS CUI [1])
Pertussis
Item
Pertussis
boolean
C0043167 (UMLS CUI [1])
Other childhood diseases
Item
Sonstiges
boolean
C0205394 (UMLS CUI [1,1])
C0489532 (UMLS CUI [1,2])
Item Group
Familienkrankheiten
C0344339 (UMLS CUI-1)
Mother
Item
Mutter
text
C0026591 (UMLS CUI [1,1])
C0344339 (UMLS CUI [1,2])
Father
Item
Vater
text
C0015671 (UMLS CUI [1,1])
C0344339 (UMLS CUI [1,2])
Other
Item
Sonstige
text
C0205394 (UMLS CUI [1,1])
C0344339 (UMLS CUI [1,2])
Item Group
Soziale Anamnese
C0424945 (UMLS CUI-1)
Occupation
Item
Beruf
text
C0028811 (UMLS CUI [1])
Item
Familienstand
integer
C0024819 (UMLS CUI [1])
Marital status
Code List
Familienstand
CL Item
verheiratet (1)
CL Item
ledig (2)
CL Item
geschieden (3)
CL Item
getrennt (4)
CL Item
verwitwet (5)
Number of children
Item
Anzahl der Kinder
integer
C2229974 (UMLS CUI [1])
Item
Häusliche Situation
integer
C0442519 (UMLS CUI [1])
Home environment
Code List
Häusliche Situation
CL Item
versorgt (1)
CL Item
nicht versorgt (2)
Item Group
Gynäkologische Anamnese
C0262926 (UMLS CUI-1)
C0205480 (UMLS CUI-2)
Age at menarche
Item
1. Regelblutung
integer
C1314691 (UMLS CUI [1])
Age at menopause
Item
Letzte Regelblutung
integer
C1629609 (UMLS CUI [1])
Item
Regelblutung
integer
C0025344 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Menstruation type
Code List
Regelblutung
CL Item
regelmäßig/unauffällig (1)
CL Item
unregelmäßig/auffällig (2)
Number of births
Item
Geburten
integer
C3172256 (UMLS CUI [1])
Number of miscarriages
Item
Fehlgeburten
integer
C0429916 (UMLS CUI [1])
Item Group
Vegetative Anamnese
C0489633 (UMLS CUI-1)
C0262926 (UMLS CUI-2)
Body height
Item
Größe
float
C0005890 (UMLS CUI [1])
Body weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Item
Gewichtsverlauf
integer
C0005911 (UMLS CUI [1])
Body weight changes
Code List
Gewichtsverlauf
CL Item
Gewicht konstant (1)
CL Item
Gewichtsreduktion (2)
CL Item
Gewichtszunahme (3)
Item
Stuhlgang
integer
C0011135 (UMLS CUI [1])
Defecation
Code List
Stuhlgang
CL Item
regelmäßig (1)
CL Item
unregelmäßig (2)
Item
Miktion
integer
C0042034 (UMLS CUI [1])
Urination
Code List
Miktion
CL Item
regelmäßig (1)
CL Item
unregelmäßig (2)
Nocturia
Item
Nykturie
boolean
C0028734 (UMLS CUI [1])
Night sweats
Item
Nachtschweiß
boolean
C0028081 (UMLS CUI [1])
Fever
Item
Fieber
boolean
C0015967 (UMLS CUI [1])
Dyspnea
Item
Luftnot
boolean
C0013404 (UMLS CUI [1])
Edema
Item
Ödeme
boolean
C0013604 (UMLS CUI [1])
Coughing
Item
Husten
boolean
C0010200 (UMLS CUI [1])
Sputum
Item
Auswurf
boolean
C0038056 (UMLS CUI [1])
Item
Appetit
integer
C0003618 (UMLS CUI [1])
Desire for food
Code List
Appetit
CL Item
normal (1)
CL Item
nicht normal (2)
Thirst
Item
Durst
float
C0039971 (UMLS CUI [1])
Item
Schlaf
integer
C0037313 (UMLS CUI [1])
Sleep
Code List
Schlaf
CL Item
auffällig (1)
CL Item
unauffällig (2)
Other
Item
Sonstiges
text
C0205394 (UMLS CUI [1,1])
C0489633 (UMLS CUI [1,2])
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