ID

21967

Description

General medical history form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Prof. Dr. med. Ludwig Kiesel

Keywords

Versions (1)
  1. 5/10/17 5/10/17 -
Copyright Holder

UKM

Uploaded on

May 10, 2017

DOI

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License

Creative Commons BY-NC 3.0
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General medical history Gynaecology UKM

German English

General medical history

1 forms  
Patient demographics
Description

Patient demographics

Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Address
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Health insurance
Description

Health insurance

Data type

integer

Alias
UMLS CUI [1]
C0021682
Address
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Physician
Description

Physician

Data type

text

Alias
UMLS CUI [1]
C2826892
Risk
Description

Risk

Data type

integer

Alias
UMLS CUI [1]
C0035647
Midwifery history
Description

Midwifery history

Alias
UMLS CUI-1
C1148523
Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Gravidity and parity
Description

Gravidity and parity

Data type

integer

Alias
UMLS CUI [1]
C0030563
Date of delivery
Description

Date of delivery

Data type

date

Alias
UMLS CUI [1]
C2053594
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Midwife
Description

Midwife

Data type

integer

Alias
UMLS CUI [1]
C0026083
Physician
Description

Physician

Data type

integer

Alias
UMLS CUI [1]
C2826892
Medical history
Description

Medical history

Allergies
Description

Allergies

Data type

integer

Alias
UMLS CUI [1]
C0020517
Medication
Description

Medication

Data type

integer

Alias
UMLS CUI [1]
C0013227
Symptoms
Description

Symptoms

Data type

text

Alias
UMLS CUI [1]
C1457887
Clinical course
Description

Clinical course

Data type

text

Alias
UMLS CUI [1]
C0449259
Diagnosis
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Diagnosis
Description

Diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0011900
Therapy
Description

Therapy

Data type

integer

Alias
UMLS CUI [1]
C0087111
Parity
Description

Parity

Data type

integer

Alias
UMLS CUI [1]
C0030563
Operations
Description

Operations

Data type

integer

Alias
UMLS CUI [1]
C0038895
Family history
Description

Family history

Data type

integer

Alias
UMLS CUI [1]
C0241889
Cigarette smoker
Description

Cigarette smoker

Data type

integer

Alias
UMLS CUI [1]
C0337667
Procedure
Description

Procedure

Alias
UMLS CUI-1
C0184661
File inpatient existing
Description

File inpatient existing

Data type

boolean

Alias
UMLS CUI [1,1]
C0016094
UMLS CUI [1,2]
C0239966
File outpatient existing
Description

File outpatient existing

Data type

boolean

Alias
UMLS CUI [1,1]
C0016094
UMLS CUI [1,2]
C0029921
Operative report
Description

Operative report

Data type

boolean

Alias
UMLS CUI [1]
C1269801
Histopathology
Description

Histopathology

Data type

boolean

Alias
UMLS CUI [1,1]
C0677043
UMLS CUI [1,2]
C0543467
Laboratory Procedures
Description

Laboratory Procedures

Data type

integer

Alias
UMLS CUI [1]
C0022885
Examination
Description

Examination

Genital
Description

Genital

Data type

integer

Alias
UMLS CUI [1]
C0017420
Vagina
Description

Vagina

Data type

integer

Alias
UMLS CUI [1]
C0042232
Cervix
Description

Cervix

Data type

integer

Alias
UMLS CUI [1]
C0007874
Uterus
Description

Uterus

Data type

integer

Alias
UMLS CUI [1]
C0007874
Uterine adnexae structure
Description

Uterine adnexae structure

Data type

integer

Alias
UMLS CUI [1]
C0001575
Rectum
Description

Rectum

Data type

integer

Alias
UMLS CUI [1]
C0001575
Mamma
Description

Mamma

Data type

integer

Alias
UMLS CUI [1]
C1268990
Skin
Description

Skin

Data type

integer

Alias
UMLS CUI [1]
C1268990
Head
Description

Head

Data type

integer

Alias
UMLS CUI [1]
C1268990
Chest
Description

Chest

Data type

integer

Alias
UMLS CUI [1]
C0817096
Heart
Description

Heart

Data type

integer

Alias
UMLS CUI [1]
C0018787
Lungs
Description

Lungs

Data type

integer

Alias
UMLS CUI [1]
C2228454
Abdomen
Description

Abdomen

Data type

integer

Alias
UMLS CUI [1]
C0000726
Kindey
Description

Kidney

Data type

integer

Alias
UMLS CUI [1]
C0022646
Limbs
Description

Limbs

Data type

integer

Alias
UMLS CUI [1]
C0015385
Nerv
Description

Nerv

Data type

integer

Alias
UMLS CUI [1]
C0027763
Vaginal Examination
Description

Vaginal Examination

Data type

text

Alias
UMLS CUI [1]
C0200048
Colposcopy
Description

Colposcopy

Data type

integer

Alias
UMLS CUI [1]
C0009417
Sonography
Description

Sonography

Data type

integer

Alias
UMLS CUI [1]
C0080264
Footer module
Description

Footer module

Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Signature
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

General medical history

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient demographics
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Health insurance
Item
Health insurance
integer
C0021682 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Physician
Item
Physician
text
C2826892 (UMLS CUI [1])
Risk
Item
Risk
integer
C0035647 (UMLS CUI [1])
Item Group
Midwifery history
C1148523 (UMLS CUI-1)
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Gravidity and parity
Item
Gravidity and parity
integer
C0030563 (UMLS CUI [1])
Date of delivery
Item
Date of delivery
date
C2053594 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Midwife
Item
Midwife
integer
C0026083 (UMLS CUI [1])
Physician
Item
Physician
integer
C2826892 (UMLS CUI [1])
Item Group
Medical history
Allergies
Item
Allergies
integer
C0020517 (UMLS CUI [1])
Medication
Item
Medication
integer
C0013227 (UMLS CUI [1])
Symptoms
Item
Symptoms
text
C1457887 (UMLS CUI [1])
Clinical course
Item
Clinical course
text
C0449259 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
integer
C0011900 (UMLS CUI [1])
Therapy
Item
Therapy
integer
C0087111 (UMLS CUI [1])
Parity
Item
Parity
integer
C0030563 (UMLS CUI [1])
Item
Operations
integer
C0038895 (UMLS CUI [1])
Operations
Code List
Operations
CL Item
secondary bleeding (1)
C0347697 (UMLS CUI-1)
CL Item
thrombosis (2)
C0040053 (UMLS CUI-1)
CL Item
transfusion (3)
C1879316 (UMLS CUI-1)
Family history
Item
Family history
integer
C0241889 (UMLS CUI [1])
Cigarette smoker
Item
Cigarette smoker
integer
C0337667 (UMLS CUI [1])
Item Group
Procedure
C0184661 (UMLS CUI-1)
File inpatient existing
Item
File inpatient existing
boolean
C0016094 (UMLS CUI [1,1])
C0239966 (UMLS CUI [1,2])
File outpatient existing
Item
File outpatient existing
boolean
C0016094 (UMLS CUI [1,1])
C0029921 (UMLS CUI [1,2])
Operative report
Item
Operative report
boolean
C1269801 (UMLS CUI [1])
Histopathology
Item
Histopathology
boolean
C0677043 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Item
Laboratory Procedures
integer
C0022885 (UMLS CUI [1])
Laboratory Procedures
Code List
Laboratory Procedures
CL Item
blood count (1)
C0005771 (UMLS CUI-1)
CL Item
quick (2)
C0483455 (UMLS CUI-1)
CL Item
ptt (3)
C0030605 (UMLS CUI-1)
CL Item
sodium (4)
C0337443 (UMLS CUI-1)
CL Item
potassium (5)
C0202194 (UMLS CUI-1)
CL Item
calcium (6)
C0201925 (UMLS CUI-1)
CL Item
crea (7)
C0201976 (UMLS CUI-1)
CL Item
got (8)
C0004002 (UMLS CUI-1)
Item Group
Examination
Item
Genital
integer
C0017420 (UMLS CUI [1])
Genital
Code List
Genital
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Vagina
integer
C0042232 (UMLS CUI [1])
Genital
Code List
Vagina
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Cervix
integer
C0007874 (UMLS CUI [1])
Genital
Code List
Cervix
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Uterus
integer
C0007874 (UMLS CUI [1])
Genital
Code List
Uterus
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Uterine adnexae structure
integer
C0001575 (UMLS CUI [1])
Genital
Code List
Uterine adnexae structure
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Rectum
integer
C0001575 (UMLS CUI [1])
Genital
Code List
Rectum
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Mamma
integer
C1268990 (UMLS CUI [1])
Genital
Code List
Mamma
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Skin
integer
C1268990 (UMLS CUI [1])
Genital
Code List
Skin
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Head
integer
C1268990 (UMLS CUI [1])
Genital
Code List
Head
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Chest
integer
C0817096 (UMLS CUI [1])
Genital
Code List
Chest
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Heart
integer
C0018787 (UMLS CUI [1])
Genital
Code List
Heart
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Lungs
integer
C2228454 (UMLS CUI [1])
Genital
Code List
Lungs
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Abdomen
integer
C0000726 (UMLS CUI [1])
Genital
Code List
Abdomen
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Kindey
integer
C0022646 (UMLS CUI [1])
Genital
Code List
Kindey
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Limbs
integer
C0015385 (UMLS CUI [1])
Genital
Code List
Limbs
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Item
Nerv
integer
C0027763 (UMLS CUI [1])
Genital
Code List
Nerv
CL Item
normal (1)
C0205307 (UMLS CUI-1)
CL Item
abnormal (2)
C0205161 (UMLS CUI-1)
Vaginal Examination
Item
Vaginal Examination
text
C0200048 (UMLS CUI [1])
Colposcopy
Item
Colposcopy
integer
C0009417 (UMLS CUI [1])
Sonography
Item
Sonography
integer
C0080264 (UMLS CUI [1])
Item Group
Footer module
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
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