ID

21864

Description

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

Keywords

  1. 5/4/17 5/4/17 -
Uploaded on

May 4, 2017

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.

Itemgroup comments for :

Item comments for :

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

Neurologic examination, University Hospital Cologne

Neurologic examination, University Hospital Cologne

Untersuchungsbogen der Neurologie
Description

Untersuchungsbogen der Neurologie

Alias
UMLS CUI-1
C0027853
Patient
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Geburtsdatum
Description

Birth Date

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1]
C0421451
dd.mm.yyyy
Fachabteilung
Description

Medical specialty

Data type

text

Alias
UMLS CUI [1]
C0037778
Station
Description

Ward

Data type

text

Alias
UMLS CUI [1]
C1305702
Syndrom
Description

Syndrome

Data type

text

Alias
UMLS CUI [1]
C0039082
Diagnose(n)
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Differentialdiagnose(n)
Description

Differential diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011906
Aktuelle Anamnese
Description

Current history

Data type

text

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

Medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Medikation bei Aufnahme
Description

Medication on admission

Data type

text

Alias
UMLS CUI [1,1]
C1553892
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0457453
Dokumentiert von
Description

Documented by

Data type

text

Measurement units
  • Name und Funktion
Alias
UMLS CUI [1]
C2361125
Name und Funktion
Dokumentiert am
Description

Date of documentation

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0920316
dd.mm.yyyy
Vegetative Anamnese
Description

Vegetative Anamnese

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0004388
Stuhlgang
Description

Defecation

Data type

text

Alias
UMLS CUI [1]
C0011135
Wasserlassen
Description

Urination

Data type

text

Alias
UMLS CUI [1]
C0042034
Schlaf
Description

Sleep

Data type

text

Alias
UMLS CUI [1]
C0037313
Appetit
Description

Appetite

Data type

text

Alias
UMLS CUI [1]
C0003618
Gewicht
Description

Body weight changes

Data type

text

Alias
UMLS CUI [1]
C0005911
Allergien
Description

Allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
Nikotin
Description

Tobacco use

Data type

integer

Measurement units
  • Zig./Tag
Alias
UMLS CUI [1]
C0543414
Zig./Tag
Alkoholkonsum
Description

Alcohol consumption

Data type

text

Alias
UMLS CUI [1]
C0001948
Sozial- und Familienanamnese
Description

Sozial- und Familienanamnese

Alias
UMLS CUI-1
C3714536
UMLS CUI-2
C0241889
Sozialanamnese
Description

Social history

Data type

text

Alias
UMLS CUI [1]
C3714536
Familienanamnese
Description

Family history

Data type

text

Alias
UMLS CUI [1]
C0241889
Klinischer Untersuchungsbefund
Description

Klinischer Untersuchungsbefund

Alias
UMLS CUI-1
C0438105
UMLS CUI-2
C0031809
Neurologischer Untersuchungsbefund (Freitext)
Description

Neurologic examination finding

Data type

text

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0243095
Kopf
Description

Head

Data type

integer

Alias
UMLS CUI [1]
C0018670
Hirnnerven I-VII
Description

Cranial nerves I-VII

Data type

integer

Alias
UMLS CUI [1]
C0010268
Hirnnerven VIII-XII
Description

Cranial nerves VIII-XII

Data type

integer

Alias
UMLS CUI [1]
C0010268
Reflexe
Description

Reflexes

Data type

integer

Alias
UMLS CUI [1]
C0436145
Spastik
Description

Spasticity

Data type

integer

Alias
UMLS CUI [1]
C0026838
Motorik
Description

Motor function

Data type

integer

Alias
UMLS CUI [1]
C0234130
Koordination, Gang, Stand
Description

Coordination, gait, ability to stand

Data type

integer

Alias
UMLS CUI [1]
C0242414
UMLS CUI [2]
C0016928
UMLS CUI [3]
C0560788
Trophik: endokrines/vegetatives System
Description

Endocrine finding, vegetative system finding

Data type

integer

Alias
UMLS CUI [1]
C0559306
UMLS CUI [2]
C0004388
Orientierende internistische Untersuchung
Description

Internistic finding

Data type

integer

Alias
UMLS CUI [1,1]
C0199209
UMLS CUI [1,2]
C0278602
Psychopathologie/Neuropsychologie
Description

Psychopathologic/neuropsychologic finding

Data type

integer

Alias
UMLS CUI [1,1]
C0033927
UMLS CUI [1,2]
C0243095
UMLS CUI [2,1]
C0027903
UMLS CUI [2,2]
C0243095
Muskelstatus Kraftgrad
Description

Motor strength examination

Data type

integer

Alias
UMLS CUI [1]
C2228462
Sensibilität intakt
Description

Sensibility

Data type

boolean

Alias
UMLS CUI [1]
C0439823
Berührung/Schmerz intakt
Description

Touch sensation, pain sensation

Data type

boolean

Alias
UMLS CUI [1]
C0576659
UMLS CUI [2]
C0558828

Similar models

Neurologic examination, University Hospital Cologne

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Untersuchungsbogen der Neurologie
C0027853 (UMLS CUI-1)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Medical specialty
Item
Fachabteilung
text
C0037778 (UMLS CUI [1])
Ward
Item
Station
text
C1305702 (UMLS CUI [1])
Syndrome
Item
Syndrom
text
C0039082 (UMLS CUI [1])
Diagnosis
Item
Diagnose(n)
text
C0011900 (UMLS CUI [1])
Differential diagnosis
Item
Differentialdiagnose(n)
text
C0011906 (UMLS CUI [1])
Current history
Item
Aktuelle Anamnese
text
C0262926 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Medical history
Item
Vorgeschichte
text
C0262926 (UMLS CUI [1])
Medication on admission
Item
Medikation bei Aufnahme
text
C1553892 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0457453 (UMLS CUI [1,3])
Documented by
Item
Dokumentiert von
text
C2361125 (UMLS CUI [1])
Date of documentation
Item
Dokumentiert am
date
C0011008 (UMLS CUI [1,1])
C0920316 (UMLS CUI [1,2])
Item Group
Vegetative Anamnese
C0262926 (UMLS CUI-1)
C0004388 (UMLS CUI-2)
Defecation
Item
Stuhlgang
text
C0011135 (UMLS CUI [1])
Urination
Item
Wasserlassen
text
C0042034 (UMLS CUI [1])
Sleep
Item
Schlaf
text
C0037313 (UMLS CUI [1])
Appetite
Item
Appetit
text
C0003618 (UMLS CUI [1])
Body weight changes
Item
Gewicht
text
C0005911 (UMLS CUI [1])
Allergies
Item
Allergien
text
C0020517 (UMLS CUI [1])
Tobacco use
Item
Nikotin
integer
C0543414 (UMLS CUI [1])
Alcohol consumption
Item
Alkoholkonsum
text
C0001948 (UMLS CUI [1])
Item Group
Sozial- und Familienanamnese
C3714536 (UMLS CUI-1)
C0241889 (UMLS CUI-2)
Social history
Item
Sozialanamnese
text
C3714536 (UMLS CUI [1])
Family history
Item
Familienanamnese
text
C0241889 (UMLS CUI [1])
Item Group
Klinischer Untersuchungsbefund
C0438105 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
Neurologic examination finding
Item
Neurologischer Untersuchungsbefund (Freitext)
text
C0027853 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Item
Kopf
integer
C0018670 (UMLS CUI [1])
Code List
Kopf
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Hirnnerven I-VII
integer
C0010268 (UMLS CUI [1])
Code List
Hirnnerven I-VII
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Hirnnerven VIII-XII
integer
C0010268 (UMLS CUI [1])
Code List
Hirnnerven VIII-XII
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Reflexe
integer
C0436145 (UMLS CUI [1])
Code List
Reflexe
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Spastik
integer
C0026838 (UMLS CUI [1])
Code List
Spastik
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Motorik
integer
C0234130 (UMLS CUI [1])
Code List
Motorik
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Koordination, Gang, Stand
integer
C0242414 (UMLS CUI [1])
C0016928 (UMLS CUI [2])
C0560788 (UMLS CUI [3])
Code List
Koordination, Gang, Stand
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Trophik: endokrines/vegetatives System
integer
C0559306 (UMLS CUI [1])
C0004388 (UMLS CUI [2])
Code List
Trophik: endokrines/vegetatives System
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Orientierende internistische Untersuchung
integer
C0199209 (UMLS CUI [1,1])
C0278602 (UMLS CUI [1,2])
Code List
Orientierende internistische Untersuchung
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Psychopathologie/Neuropsychologie
integer
C0033927 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0027903 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
Code List
Psychopathologie/Neuropsychologie
CL Item
o.B. (1)
CL Item
pathologischer Befund (2)
Item
Muskelstatus Kraftgrad
integer
C2228462 (UMLS CUI [1])
Code List
Muskelstatus Kraftgrad
CL Item
5 (1)
CL Item
4 (2)
CL Item
3 (3)
CL Item
2 (4)
CL Item
1 (5)
CL Item
0 (6)
Sensibility
Item
Sensibilität intakt
boolean
C0439823 (UMLS CUI [1])
Touch sensation, pain sensation
Item
Berührung/Schmerz intakt
boolean
C0576659 (UMLS CUI [1])
C0558828 (UMLS CUI [2])

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

Fields marked with * are required.

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