ID

11213

Beskrivning

Form from HIS OpenVistA

Nyckelord

  1. 2012-02-25 2012-02-25 -
  2. 2014-08-09 2014-08-09 - Martin Dugas
  3. 2015-06-25 2015-06-25 - Martin Dugas
Uppladdad den

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
Beskrivning

BASIC EVALUATION

Alter
Beskrivning

Age

Datatyp

integer

Måttenheter
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Geschlecht
Beskrivning

Gender

Datatyp

integer

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

Height

Datatyp

float

Måttenheter
  • cm
Alias
LOINC Version 232
MTHU005354
UMLS CUI-1
C0005890
cm
Gewicht
Beskrivning

Current Weight

Datatyp

integer

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

Weight change

Datatyp

integer

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

IBW

Datatyp

integer

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

Weight status

Datatyp

integer

Diät
Beskrivning

Diet

Datatyp

text

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

PO intake

Datatyp

string

COMMENTS
Beskrivning

COMMENTS

Patient triggered for problem swallowing difficulty
Beskrivning

Patient triggered for problem swallowing difficulty

Datatyp

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
Beskrivning

Patient states no problems with swallowing difficulty

Datatyp

boolean

Swallow difficulty due to sore throat. Nursing Notified.
Beskrivning

Swallow difficulty due to sore throat. Nursing Notified.

Datatyp

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.
Beskrivning

Patient needs diet consistency change to diet.

Datatyp

boolean

Patient needs special foods of appropriate consistency.
Beskrivning

Patient needs special foods of appropriate consistency.

Datatyp

boolean

other
Beskrivning

other

Datatyp

string

Patient triggered for poor po intake > 5 days.
Beskrivning

Patient triggered for poor po intake > 5 days.

Datatyp

boolean

Patient requests oral supplements of
Beskrivning

Patient requests oral supplements of

Datatyp

string

Patient states no problems with po intake.
Beskrivning

Patient states no problems with po intake.

Datatyp

boolean

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

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

Datatyp

boolean

Patient states no appetite.
Beskrivning

Patient states no appetite.

Datatyp

boolean

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

Patient states unable to eat certain foods:

Datatyp

string

Patient started on nutrition support
Beskrivning

Patient started on nutrition support

Datatyp

boolean

other
Beskrivning

other

Datatyp

string

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

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

Datatyp

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.
Beskrivning

Patient states no weight loss.

Datatyp

boolean

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

Patient was on a diet, weight loss was intentional.

Datatyp

boolean

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

Patient states weight loss due to increased activity.

Datatyp

boolean

other
Beskrivning

other

Datatyp

string

Patient triggered for food allergies
Beskrivning

Patient triggered for food allergies

Datatyp

boolean

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

Patient states they have no food allergies/intolerances.

Datatyp

boolean

Patient has no food intolerances to
Beskrivning

Patient has no food intolerances to

Datatyp

string

All food allergies/intolerances were identified.
Beskrivning

All food allergies/intolerances were identified.

Datatyp

boolean

other
Beskrivning

other

Datatyp

string

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

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

Datatyp

boolean

Patient is greater than 16 years old of age.
Beskrivning

Patient is greater than 16 years old of age.

Datatyp

boolean

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

Patient is not pregnant.

Datatyp

boolean

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

other

Datatyp

string

Patient triggered for being pregnant and on special diet.
Beskrivning

Patient triggered for being pregnant and on special diet.

Datatyp

boolean

Patient is not pregnant.
Beskrivning

Patient is not pregnant.

Datatyp

boolean

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

Patient is not on a special diet.

Datatyp

boolean

Patient is on diet for
Beskrivning

Patient is on diet for

Datatyp

string

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

Patient understands special diet, does not need additional information.

Datatyp

boolean

Patient does not understand special diet.
Beskrivning

Patient does not understand special diet.

Datatyp

boolean

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

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

Datatyp

boolean

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

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

Datatyp

boolean

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

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

Datatyp

boolean

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

Patient seen due to extended length of stay in hospital.

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0023303
other
Beskrivning

other

Datatyp

string

GOALS
Beskrivning

GOALS

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

Patient to resume po intake (if currently NPO).

Datatyp

boolean

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

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

Datatyp

boolean

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

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

Datatyp

boolean

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

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

Datatyp

boolean

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

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

Datatyp

boolean

Weight gain of 1-2 lbs per week.
Beskrivning

Weight gain of 1-2 lbs per week.

Datatyp

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.
Beskrivning

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

Datatyp

boolean

Patient to understand diet currently ordered by physician.
Beskrivning

Patient to understand diet currently ordered by physician.

Datatyp

boolean

Patient to be seen by dietician due to:
Beskrivning

Patient to be seen by dietician due to:

Datatyp

string

other
Beskrivning

other

Datatyp

string

LEVEL OF CARE
Beskrivning

LEVEL OF CARE

Pflegestufe
Beskrivning

Level of care

Datatyp

string

Alias
UMLS CUI 2011AA
C0851273
PLAN
Beskrivning

PLAN

Continue with diet as currently ordered.
Beskrivning

Continue with diet as currently ordered.

Datatyp

boolean

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

Advance diet as tolerated.

Datatyp

boolean

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

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

Datatyp

boolean

Encourage patient to mark menu selections.
Beskrivning

Encourage patient to mark menu selections.

Datatyp

boolean

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

Obtain food preferences. Place in computer and notify kitchen.

Datatyp

boolean

Discuss adding oral supplement with nursing or dietician.
Beskrivning

Discuss adding oral supplement with nursing or dietician.

Datatyp

boolean

Provide snacks to increase po intake.
Beskrivning

Provide snacks to increase po intake.

Datatyp

boolean

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

Notify diet office of food allergens or intolerances via computer.

Datatyp

boolean

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

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

Datatyp

boolean

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

Inform dietician of need for extensive diet education on diet.

Datatyp

boolean

Follow patient per protocol.
Beskrivning

Follow patient per protocol.

Datatyp

boolean

Refer to dietician.
Beskrivning

Refer to dietician

Datatyp

boolean

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

other

Datatyp

string

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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