ID

11213

Beschreibung

Form from HIS OpenVistA

Stichworte

Versionen (3)
  1. 25.02.12 25.02.12 -
  2. 09.08.14 09.08.14 - Martin Dugas
  3. 25.06.15 25.06.15 - Martin Dugas
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25. Juni 2015

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NUTRITION SCREENING CONSULT RESULTS MAIN

Deutsch Englisch

HIS

1 Formulare  
  1. StudyEvent: HIS
    1. HIS
BASIC EVALUATION
Beschreibung

BASIC EVALUATION

Alter
Beschreibung

Age

Datentyp

integer

Maßeinheiten
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Geschlecht
Beschreibung

Gender

Datentyp

integer

Alias
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
UMLS CUI-1
C0079399
Größe
Beschreibung

Height

Datentyp

float

Maßeinheiten
  • cm
Alias
LOINC Version 232
MTHU005354
UMLS CUI-1
C0005890
cm
Gewicht
Beschreibung

Current Weight

Datentyp

integer

Alias
UMLS CUI 2011AA
C1305866
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Gewichtsänderung
Beschreibung

Weight change

Datentyp

integer

Alias
UMLS CUI 2011AA
C0005911
SNOMED CT 2011_0131
248346009
LOINC Version 232
MTHU021183
Idealgewicht
Beschreibung

IBW

Datentyp

integer

Alias
UMLS CUI 2011AA
C0421272
SNOMED CT 2011_0131
170804003
LOINC Version 232
MTHU031532
Weight status (underweight| normal| overweight| obese)
Beschreibung

Weight status

Datentyp

integer

Diät
Beschreibung

Diet

Datentyp

text

Alias
SNOMED CT 2011_0131
41829006
UMLS CUI-1
C0012155
PO intake
Beschreibung

PO intake

Datentyp

string

COMMENTS
Beschreibung

COMMENTS

Patient triggered for problem swallowing difficulty
Beschreibung

Patient triggered for problem swallowing difficulty

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0392678
SNOMED CT 2011_0131
399122003
MedDRA 14.1
10042647
LOINC Version 232
MTHU020878
Patient states no problems with swallowing difficulty
Beschreibung

Patient states no problems with swallowing difficulty

Datentyp

boolean

Swallow difficulty due to sore throat. Nursing Notified.
Beschreibung

Swallow difficulty due to sore throat. Nursing Notified.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0242429
SNOMED CT 2011_0131
267102003
MedDRA 14.1
10041367
ICD-10-CM Version 2010
R07.0
ICD-9-CM Version 2011
784.1
CTCAE 1105E
E13575
Patient needs diet consistency change to diet.
Beschreibung

Patient needs diet consistency change to diet.

Datentyp

boolean

Patient needs special foods of appropriate consistency.
Beschreibung

Patient needs special foods of appropriate consistency.

Datentyp

boolean

other
Beschreibung

other

Datentyp

string

Patient triggered for poor po intake > 5 days.
Beschreibung

Patient triggered for poor po intake > 5 days.

Datentyp

boolean

Patient requests oral supplements of
Beschreibung

Patient requests oral supplements of

Datentyp

string

Patient states no problems with po intake.
Beschreibung

Patient states no problems with po intake.

Datentyp

boolean

Patient states po intake improved>50% at all meals.
Beschreibung

Patient states po intake improved>50% at all meals.

Datentyp

boolean

Patient states no appetite.
Beschreibung

Patient states no appetite.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0232462
SNOMED CT 2011_0131
64379006
MedDRA 14.1
10061428
Patient states unable to eat certain foods:
Beschreibung

Patient states unable to eat certain foods:

Datentyp

string

Patient started on nutrition support
Beschreibung

Patient started on nutrition support

Datentyp

boolean

other
Beschreibung

other

Datentyp

string

Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
Beschreibung

Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0936227
SNOMED CT 2011_0131
267024001
MedDRA 14.1
10000159
ICD-10-CM Version 2010
R63.4
Patient states no weight loss.
Beschreibung

Patient states no weight loss.

Datentyp

boolean

Patient was on a diet, weight loss was intentional.
Beschreibung

Patient was on a diet, weight loss was intentional.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Patient states weight loss due to increased activity.
Beschreibung

Patient states weight loss due to increased activity.

Datentyp

boolean

other
Beschreibung

other

Datentyp

string

Patient triggered for food allergies
Beschreibung

Patient triggered for food allergies

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0016470
SNOMED CT 2011_0131
414285001
MedDRA 14.1
10016946
Patient states they have no food allergies/intolerances.
Beschreibung

Patient states they have no food allergies/intolerances.

Datentyp

boolean

Patient has no food intolerances to
Beschreibung

Patient has no food intolerances to

Datentyp

string

All food allergies/intolerances were identified.
Beschreibung

All food allergies/intolerances were identified.

Datentyp

boolean

other
Beschreibung

other

Datentyp

string

Patient triggered for being pregnant and less than 16 years old of age.
Beschreibung

Patient triggered for being pregnant and less than 16 years old of age.

Datentyp

boolean

Patient is greater than 16 years old of age.
Beschreibung

Patient is greater than 16 years old of age.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0001779
SNOMED CT 2011_0131
397669002
Patient is not pregnant.
Beschreibung

Patient is not pregnant.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0232973
SNOMED CT 2011_0131
60001007
other
Beschreibung

other

Datentyp

string

Patient triggered for being pregnant and on special diet.
Beschreibung

Patient triggered for being pregnant and on special diet.

Datentyp

boolean

Patient is not pregnant.
Beschreibung

Patient is not pregnant.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0232973
SNOMED CT 2011_0131
60001007
Patient is not on a special diet.
Beschreibung

Patient is not on a special diet.

Datentyp

boolean

Patient is on diet for
Beschreibung

Patient is on diet for

Datentyp

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Patient understands special diet, does not need additional information.
Beschreibung

Patient understands special diet, does not need additional information.

Datentyp

boolean

Patient does not understand special diet.
Beschreibung

Patient does not understand special diet.

Datentyp

boolean

Patient triggered for being below 10th percentile of Pediatric Growth Charts.
Beschreibung

Patient triggered for being below 10th percentile of Pediatric Growth Charts.

Datentyp

boolean

Patient is at 50th percentile or greater on growth charts.
Beschreibung

Patient is at 50th percentile or greater on growth charts.

Datentyp

boolean

Patient is between 25th and 50th percentile on growth charts.
Beschreibung

Patient is between 25th and 50th percentile on growth charts.

Datentyp

boolean

Patient seen due to extended length of stay in hospital.
Beschreibung

Patient seen due to extended length of stay in hospital.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0023303
other
Beschreibung

other

Datentyp

string

GOALS
Beschreibung

GOALS

Patient to resume po intake (if currently NPO).
Beschreibung

Patient to resume po intake (if currently NPO).

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1512806
Patient to transition to solid foods (if on CL or FL diet).
Beschreibung

Patient to transition to solid foods (if on CL or FL diet).

Datentyp

boolean

Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
Beschreibung

Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.

Datentyp

boolean

Patient to continue po intake>75% at meals/snacks.
Beschreibung

Patient to continue po intake>75% at meals/snacks.

Datentyp

boolean

PO intake to be greater than 50% at all meals/snacks.
Beschreibung

PO intake to be greater than 50% at all meals/snacks.

Datentyp

boolean

Weight gain of 1-2 lbs per week.
Beschreibung

Weight gain of 1-2 lbs per week.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0043094
SNOMED CT 2011_0131
262286000
MedDRA 14.1
10047899
LOINC Version 232
MTHU020882
CTCAE 1105E
E12224
Patient will not receive foods that they have indicated as being allergic or intolerate to.
Beschreibung

Patient will not receive foods that they have indicated as being allergic or intolerate to.

Datentyp

boolean

Patient to understand diet currently ordered by physician.
Beschreibung

Patient to understand diet currently ordered by physician.

Datentyp

boolean

Patient to be seen by dietician due to:
Beschreibung

Patient to be seen by dietician due to:

Datentyp

string

other
Beschreibung

other

Datentyp

string

LEVEL OF CARE
Beschreibung

LEVEL OF CARE

Pflegestufe
Beschreibung

Level of care

Datentyp

string

Alias
UMLS CUI 2011AA
C0851273
PLAN
Beschreibung

PLAN

Continue with diet as currently ordered.
Beschreibung

Continue with diet as currently ordered.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Advance diet as tolerated.
Beschreibung

Advance diet as tolerated.

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Explain menu process. Encourage continued good intake > 50%.
Beschreibung

Explain menu process. Encourage continued good intake > 50%.

Datentyp

boolean

Encourage patient to mark menu selections.
Beschreibung

Encourage patient to mark menu selections.

Datentyp

boolean

Obtain food preferences. Place in computer and notify kitchen.
Beschreibung

Obtain food preferences. Place in computer and notify kitchen.

Datentyp

boolean

Discuss adding oral supplement with nursing or dietician.
Beschreibung

Discuss adding oral supplement with nursing or dietician.

Datentyp

boolean

Provide snacks to increase po intake.
Beschreibung

Provide snacks to increase po intake.

Datentyp

boolean

Notify diet office of food allergens or intolerances via computer.
Beschreibung

Notify diet office of food allergens or intolerances via computer.

Datentyp

boolean

Provided educational handout on diet. Give RD contact information for further questions.
Beschreibung

Provided educational handout on diet. Give RD contact information for further questions.

Datentyp

boolean

Inform dietician of need for extensive diet education on diet.
Beschreibung

Inform dietician of need for extensive diet education on diet.

Datentyp

boolean

Follow patient per protocol.
Beschreibung

Follow patient per protocol.

Datentyp

boolean

Refer to dietician.
Beschreibung

Refer to dietician

Datentyp

boolean

Alias
SNOMED CT 2011_0131
159033005
UMLS CUI-1
C0237083
other
Beschreibung

other

Datentyp

string

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Ähnliche Modelle

HIS

1 Formulare
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Item
Geschlecht
integer
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
C0079399 (UMLS CUI-1)
Gender
Code List
Geschlecht
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
Height
Item
Größe
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Current Weight
Item
Gewicht
integer
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Weight change
Item
Gewichtsänderung
integer
C0005911 (UMLS CUI 2011AA)
248346009 (SNOMED CT 2011_0131)
MTHU021183 (LOINC Version 232)
IBW
Item
Idealgewicht
integer
C0421272 (UMLS CUI 2011AA)
170804003 (SNOMED CT 2011_0131)
MTHU031532 (LOINC Version 232)
Weight status
Item
Weight status (underweight| normal| overweight| obese)
integer
Diet
Item
Diät
text
41829006 (SNOMED CT 2011_0131)
C0012155 (UMLS CUI-1)
PO intake
Item
PO intake
string
Item Group
Patient triggered for problem swallowing difficulty
Item
Patient triggered for problem swallowing difficulty
boolean
C0392678 (UMLS CUI 2011AA)
399122003 (SNOMED CT 2011_0131)
10042647 (MedDRA 14.1)
MTHU020878 (LOINC Version 232)
Patient states no problems with swallowing difficulty
Item
Patient states no problems with swallowing difficulty
boolean
Swallow difficulty due to sore throat. Nursing Notified.
Item
Swallow difficulty due to sore throat. Nursing Notified.
boolean
C0242429 (UMLS CUI 2011AA)
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
Patient needs diet consistency change to diet.
Item
Patient needs diet consistency change to diet.
boolean
Patient needs special foods of appropriate consistency.
Item
Patient needs special foods of appropriate consistency.
boolean
other
Item
other
string
Patient triggered for poor po intake > 5 days.
Item
Patient triggered for poor po intake > 5 days.
boolean
Patient requests oral supplements of
Item
Patient requests oral supplements of
string
Patient states no problems with po intake.
Item
Patient states no problems with po intake.
boolean
Patient states po intake improved>50% at all meals.
Item
Patient states po intake improved>50% at all meals.
boolean
Patient states no appetite.
Item
Patient states no appetite.
boolean
C0232462 (UMLS CUI 2011AA)
64379006 (SNOMED CT 2011_0131)
10061428 (MedDRA 14.1)
Patient states unable to eat certain foods:
Item
Patient states unable to eat certain foods:
string
Patient started on nutrition support
Item
Patient started on nutrition support
boolean
other
Item
other
string
Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
Item
Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Patient states no weight loss.
Item
Patient states no weight loss.
boolean
Patient was on a diet, weight loss was intentional.
Item
Patient was on a diet, weight loss was intentional.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Patient states weight loss due to increased activity.
Item
Patient states weight loss due to increased activity.
boolean
other
Item
other
string
Patient triggered for food allergies
Item
Patient triggered for food allergies
boolean
C0016470 (UMLS CUI 2011AA)
414285001 (SNOMED CT 2011_0131)
10016946 (MedDRA 14.1)
Patient states they have no food allergies/intolerances.
Item
Patient states they have no food allergies/intolerances.
boolean
Patient has no food intolerances to
Item
Patient has no food intolerances to
string
All food allergies/intolerances were identified.
Item
All food allergies/intolerances were identified.
boolean
other
Item
other
string
Patient triggered for being pregnant and less than 16 years old of age.
Item
Patient triggered for being pregnant and less than 16 years old of age.
boolean
Patient is greater than 16 years old of age.
Item
Patient is greater than 16 years old of age.
boolean
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Patient is not pregnant.
Item
Patient is not pregnant.
boolean
C0232973 (UMLS CUI 2011AA)
60001007 (SNOMED CT 2011_0131)
other
Item
other
string
Patient triggered for being pregnant and on special diet.
Item
Patient triggered for being pregnant and on special diet.
boolean
Patient is not pregnant.
Item
Patient is not pregnant.
boolean
C0232973 (UMLS CUI 2011AA)
60001007 (SNOMED CT 2011_0131)
Patient is not on a special diet.
Item
Patient is not on a special diet.
boolean
Patient is on diet for
Item
Patient is on diet for
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Patient understands special diet, does not need additional information.
Item
Patient understands special diet, does not need additional information.
boolean
Patient does not understand special diet.
Item
Patient does not understand special diet.
boolean
Patient triggered for being below 10th percentile of Pediatric Growth Charts.
Item
Patient triggered for being below 10th percentile of Pediatric Growth Charts.
boolean
Patient is at 50th percentile or greater on growth charts.
Item
Patient is at 50th percentile or greater on growth charts.
boolean
Patient is between 25th and 50th percentile on growth charts.
Item
Patient is between 25th and 50th percentile on growth charts.
boolean
Patient seen due to extended length of stay in hospital.
Item
Patient seen due to extended length of stay in hospital.
boolean
C0023303 (UMLS CUI 2011AA)
other
Item
other
string
Item Group
Patient to resume po intake (if currently NPO).
Item
Patient to resume po intake (if currently NPO).
boolean
C1512806 (UMLS CUI 2011AA)
Patient to transition to solid foods (if on CL or FL diet).
Item
Patient to transition to solid foods (if on CL or FL diet).
boolean
Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
Item
Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
boolean
Patient to continue po intake>75% at meals/snacks.
Item
Patient to continue po intake>75% at meals/snacks.
boolean
PO intake to be greater than 50% at all meals/snacks.
Item
PO intake to be greater than 50% at all meals/snacks.
boolean
Weight gain of 1-2 lbs per week.
Item
Weight gain of 1-2 lbs per week.
boolean
C0043094 (UMLS CUI 2011AA)
262286000 (SNOMED CT 2011_0131)
10047899 (MedDRA 14.1)
MTHU020882 (LOINC Version 232)
E12224 (CTCAE 1105E)
Patient will not receive foods that they have indicated as being allergic or intolerate to.
Item
Patient will not receive foods that they have indicated as being allergic or intolerate to.
boolean
Patient to understand diet currently ordered by physician.
Item
Patient to understand diet currently ordered by physician.
boolean
Patient to be seen by dietician due to:
Item
Patient to be seen by dietician due to:
string
other
Item
other
string
Item Group
Level of care
Item
Pflegestufe
string
C0851273 (UMLS CUI 2011AA)
Item Group
Continue with diet as currently ordered.
Item
Continue with diet as currently ordered.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Advance diet as tolerated.
Item
Advance diet as tolerated.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Explain menu process. Encourage continued good intake > 50%.
Item
Explain menu process. Encourage continued good intake > 50%.
boolean
Encourage patient to mark menu selections.
Item
Encourage patient to mark menu selections.
boolean
Obtain food preferences. Place in computer and notify kitchen.
Item
Obtain food preferences. Place in computer and notify kitchen.
boolean
Discuss adding oral supplement with nursing or dietician.
Item
Discuss adding oral supplement with nursing or dietician.
boolean
Provide snacks to increase po intake.
Item
Provide snacks to increase po intake.
boolean
Notify diet office of food allergens or intolerances via computer.
Item
Notify diet office of food allergens or intolerances via computer.
boolean
Provided educational handout on diet. Give RD contact information for further questions.
Item
Provided educational handout on diet. Give RD contact information for further questions.
boolean
Inform dietician of need for extensive diet education on diet.
Item
Inform dietician of need for extensive diet education on diet.
boolean
Follow patient per protocol.
Item
Follow patient per protocol.
boolean
Refer to dietician
Item
Refer to dietician.
boolean
159033005 (SNOMED CT 2011_0131)
C0237083 (UMLS CUI-1)
other
Item
other
string
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