ID

11213

Beschrijving

Form from HIS OpenVistA

Trefwoorden

  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
Geüploaded op

25 juni 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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NUTRITION SCREENING CONSULT RESULTS MAIN

  1. StudyEvent: HIS
    1. HIS
BASIC EVALUATION
Beschrijving

BASIC EVALUATION

Alter
Beschrijving

Age

Datatype

integer

Maateenheden
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Geschlecht
Beschrijving

Gender

Datatype

integer

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

Height

Datatype

float

Maateenheden
  • cm
Alias
LOINC Version 232
MTHU005354
UMLS CUI-1
C0005890
cm
Gewicht
Beschrijving

Current Weight

Datatype

integer

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

Weight change

Datatype

integer

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

IBW

Datatype

integer

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

Weight status

Datatype

integer

Diät
Beschrijving

Diet

Datatype

text

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

PO intake

Datatype

string

COMMENTS
Beschrijving

COMMENTS

Patient triggered for problem swallowing difficulty
Beschrijving

Patient triggered for problem swallowing difficulty

Datatype

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
Beschrijving

Patient states no problems with swallowing difficulty

Datatype

boolean

Swallow difficulty due to sore throat. Nursing Notified.
Beschrijving

Swallow difficulty due to sore throat. Nursing Notified.

Datatype

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.
Beschrijving

Patient needs diet consistency change to diet.

Datatype

boolean

Patient needs special foods of appropriate consistency.
Beschrijving

Patient needs special foods of appropriate consistency.

Datatype

boolean

other
Beschrijving

other

Datatype

string

Patient triggered for poor po intake > 5 days.
Beschrijving

Patient triggered for poor po intake > 5 days.

Datatype

boolean

Patient requests oral supplements of
Beschrijving

Patient requests oral supplements of

Datatype

string

Patient states no problems with po intake.
Beschrijving

Patient states no problems with po intake.

Datatype

boolean

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

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

Datatype

boolean

Patient states no appetite.
Beschrijving

Patient states no appetite.

Datatype

boolean

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

Patient states unable to eat certain foods:

Datatype

string

Patient started on nutrition support
Beschrijving

Patient started on nutrition support

Datatype

boolean

other
Beschrijving

other

Datatype

string

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

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

Datatype

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.
Beschrijving

Patient states no weight loss.

Datatype

boolean

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

Patient was on a diet, weight loss was intentional.

Datatype

boolean

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

Patient states weight loss due to increased activity.

Datatype

boolean

other
Beschrijving

other

Datatype

string

Patient triggered for food allergies
Beschrijving

Patient triggered for food allergies

Datatype

boolean

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

Patient states they have no food allergies/intolerances.

Datatype

boolean

Patient has no food intolerances to
Beschrijving

Patient has no food intolerances to

Datatype

string

All food allergies/intolerances were identified.
Beschrijving

All food allergies/intolerances were identified.

Datatype

boolean

other
Beschrijving

other

Datatype

string

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

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

Datatype

boolean

Patient is greater than 16 years old of age.
Beschrijving

Patient is greater than 16 years old of age.

Datatype

boolean

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

Patient is not pregnant.

Datatype

boolean

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

other

Datatype

string

Patient triggered for being pregnant and on special diet.
Beschrijving

Patient triggered for being pregnant and on special diet.

Datatype

boolean

Patient is not pregnant.
Beschrijving

Patient is not pregnant.

Datatype

boolean

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

Patient is not on a special diet.

Datatype

boolean

Patient is on diet for
Beschrijving

Patient is on diet for

Datatype

string

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

Patient understands special diet, does not need additional information.

Datatype

boolean

Patient does not understand special diet.
Beschrijving

Patient does not understand special diet.

Datatype

boolean

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

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

Datatype

boolean

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

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

Datatype

boolean

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

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

Datatype

boolean

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

Patient seen due to extended length of stay in hospital.

Datatype

boolean

Alias
UMLS CUI 2011AA
C0023303
other
Beschrijving

other

Datatype

string

GOALS
Beschrijving

GOALS

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

Patient to resume po intake (if currently NPO).

Datatype

boolean

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

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

Datatype

boolean

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

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

Datatype

boolean

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

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

Datatype

boolean

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

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

Datatype

boolean

Weight gain of 1-2 lbs per week.
Beschrijving

Weight gain of 1-2 lbs per week.

Datatype

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.
Beschrijving

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

Datatype

boolean

Patient to understand diet currently ordered by physician.
Beschrijving

Patient to understand diet currently ordered by physician.

Datatype

boolean

Patient to be seen by dietician due to:
Beschrijving

Patient to be seen by dietician due to:

Datatype

string

other
Beschrijving

other

Datatype

string

LEVEL OF CARE
Beschrijving

LEVEL OF CARE

Pflegestufe
Beschrijving

Level of care

Datatype

string

Alias
UMLS CUI 2011AA
C0851273
PLAN
Beschrijving

PLAN

Continue with diet as currently ordered.
Beschrijving

Continue with diet as currently ordered.

Datatype

boolean

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

Advance diet as tolerated.

Datatype

boolean

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

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

Datatype

boolean

Encourage patient to mark menu selections.
Beschrijving

Encourage patient to mark menu selections.

Datatype

boolean

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

Obtain food preferences. Place in computer and notify kitchen.

Datatype

boolean

Discuss adding oral supplement with nursing or dietician.
Beschrijving

Discuss adding oral supplement with nursing or dietician.

Datatype

boolean

Provide snacks to increase po intake.
Beschrijving

Provide snacks to increase po intake.

Datatype

boolean

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

Notify diet office of food allergens or intolerances via computer.

Datatype

boolean

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

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

Datatype

boolean

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

Inform dietician of need for extensive diet education on diet.

Datatype

boolean

Follow patient per protocol.
Beschrijving

Follow patient per protocol.

Datatype

boolean

Refer to dietician.
Beschrijving

Refer to dietician

Datatype

boolean

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

other

Datatype

string

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
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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