ID

11249

Description

Form from HIS OpenVistA

Keywords

Versions (4)
  1. 2/23/12 2/23/12 -
  2. 8/7/14 8/7/14 - Martin Dugas
  3. 8/7/14 8/7/14 - Martin Dugas
  4. 6/26/15 6/26/15 - Martin Dugas
Uploaded on

June 26, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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H and P or consult specialty

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
H and P or consult specialty
Description

H and P or consult specialty

Reason for visit
Description

Reason for visit

Data type

string

Chief complaint (CC)
Description

CHIEF COMPLAINT

Data type

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
HISTORY OF PRESENT ILLNESS
Description

HISTORY OF PRESENT ILLNESS

History of present illness
Description

HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)

Data type

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
SOURCE(S) OF HISTORY (Patient, Family, Outside records, Unobtainable)
Description

SOURCE(S) OF HISTORY

Data type

integer

SOURCE(S) OF HISTORY comment
Description

SOURCE(S) OF HISTORY comment

Data type

string

REVIEW OF SYSTEMS
Description

REVIEW OF SYSTEMS

REVIEW OF SYSTEMS: see form Review of systems
Description

REVIEW OF SYSTEMS: see form Review of systems

Data type

string

PAST HISTORY
Description

PAST HISTORY

Adult disease
Description

Adult Illness

Data type

string

Alias
UMLS CUI 2011AA
C0277562
SNOMED CT 2011_0131
64342008
Childhood Illness
Description

History of childhood diseases

Data type

string

Alias
UMLS CUI 2011AA
C0489532
LOINC Version 232
MTHU001066
Prior Surgery, History of (H/O) surgery, Past surgical history
Description

Surgeries

Data type

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Traumatic injury, trauma
Description

Injury

Data type

string

Alias
UMLS CUI 2011AA
C0175677
SNOMED CT 2011_0131
417746004
MedDRA 14.1
10022116
ICD-10-CM Version 2010
T14.9
Female Specific History
Description

Female Specific History

Date of last menstrual period (LMP)
Description

Date of last menstrual period

Data type

date

Alias
UMLS CUI 2011AA
C0425932
SNOMED CT 2011_0131
21840007
LOINC Version 232
MTHU024536
Date of last Papanicolaou test (PAP)
Description

Date of last PAP

Data type

date

Pap smear, smear cervix, vaginal smear, Papanicolaou Test
Description

last PAP Results

Data type

string

Alias
UMLS CUI 2011AA
C0079104
MedDRA 14.1
10041205
Date of last mammogram (MMG)
Description

Date of last MMG

Data type

date

Mammogram
Description

last MMG Results

Data type

string

Alias
UMLS CUI 2011AA
C0024671
SNOMED CT 2011_0131
71651007
MedDRA 14.1
10026735
Age at menarche
Description

Age at menarche

Data type

integer

Alias
UMLS CUI 2011AA
C1314691
SNOMED CT 2011_0131
398700009
LOINC Version 232
MTHU018825
Menstruation, Menses
Description

Describe Menses

Data type

string

Alias
UMLS CUI 2011AA
C0025344
SNOMED CT 2011_0131
248957007
Contraception, Birth control
Description

Birth Control

Data type

string

Alias
UMLS CUI 2011AA
C0700589
SNOMED CT 2011_0131
146680009
MedDRA 14.1
10010808
Pregnancy, Gestation
Description

Pregnancies

Data type

string

Alias
UMLS CUI 2011AA
C0032961
SNOMED CT 2011_0131
289908002
MedDRA 14.1
10036556
LOINC Version 232
MTHU035048
Abortion, Pregnancy with abortive outcome
Description

Abortions

Data type

string

Alias
UMLS CUI 2011AA
C0156543
SNOMED CT 2011_0131
70317007
MedDRA 14.1
10000210
LOINC Version 232
MTHU002834
ICD-10-CM Version 2010
O00-O08
ICD-9-CM Version 2011
637
Number of full term pregnancies
Description

Number of full term pregnancies

Data type

integer

Number of spontaneous abortions
Description

Number of spontaneous abortions

Data type

integer

Number of therapeutic abortions
Description

Number of therapeutic abortions

Data type

integer

Number of other types Abortions
Description

Number of other types Abortions

Data type

integer

Age at first pregnancy
Description

Age at first pregnancy

Data type

integer

FAMILY HISTORY
Description

FAMILY HISTORY

Family history (FH)
Description

Family history: see form Family Hx

Data type

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
SOCIAL HISTORY
Description

SOCIAL HISTORY

Social and personal history, Social and personal circumstances
Description

Social history: see form Social History

Data type

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
ALLERGIES
Description

ALLERGIES

No Known Allergies
Description

No Known Allergies

Data type

boolean

Hypersensitivity
Description

Allergies text

Data type

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
MEDICATIONS
Description

MEDICATIONS

Inpatient Medications
Description

Inpatient medications

Data type

string

Alias
UMLS CUI 2011AA
C0013227
current medication list, active medication
Description

Active medications

Data type

string

Alias
UMLS CUI 2011AA
C1553892
Home Medications
Description

Home medications

Data type

string

Alias
UMLS CUI 2011AA
C0013227
PHYSICAL EXAM - General
Description

PHYSICAL EXAM - General

VITAL signs
Description

VITALS

Data type

string

Alias
UMLS CUI 2011AA
C0518766
SNOMED CT 2011_0131
46680005
LOINC Version 232
MTHU024540
Temperature
Description

Temperature

Data type

float

Measurement units
  • °C
Alias
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
UMLS CUI-1
C0039476
°C
Pulse
Description

Pulse

Data type

integer

Measurement units
  • beats/min
Alias
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
UMLS CUI-1
C0232117
beats/min
Respiration rate, Breathing rate (BR)
Description

Respiration rate, Breathing rate (BR)

Data type

integer

Measurement units
  • /min
Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
/min
Blood pressure (BP)
Description

Blood pressure (BP)

Data type

integer

Measurement units
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
Pain
Description

Pain

Data type

string

Alias
UMLS CUI 2011AA
C0030193
SNOMED CT 2011_0131
22253000
MedDRA 14.1
10033371
LOINC Version 232
MTHU029813
ICD-10-CM Version 2010
R52
ICD-9-CM Version 2011
338-338.9
CTCAE 1105E
E11167
Body weight
Description

Body weight

Data type

float

Measurement units
  • kg
Alias
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
UMLS CUI-1
C0005910
kg
GENERAL
Description

GENERAL

Data type

text

Alias
UMLS CUI-1
C1148438
PHYSICAL EXAM - HEAD
Description

PHYSICAL EXAM - HEAD

HEAD (Normocephalic, atraumatic)
Description

HEAD

Data type

boolean

Head
Description

Head text (significant for:)

Data type

string

Alias
UMLS CUI 2011AA
C0018670
SNOMED CT 2011_0131
69536005
LOINC Version 232
MTHU001435
PHYSICAL EXAM - EYES
Description

PHYSICAL EXAM - EYES

EYES (Pupils are RRE and react to light and accomodation, Conjunctivae pink and moist, Extraocular muscles intact)
Description

EYES

Data type

boolean

Alias
UMLS CUI 2011AA
C0015392
SNOMED CT 2011_0131
81745001
LOINC Version 232
MTHU000064
Pupil
Description

Pupils

Data type

string

Alias
UMLS CUI 2011AA
C0034121
SNOMED CT 2011_0131
392406005
LOINC Version 232
MTHU015063
conjunctiva
Description

Conjunctivae

Data type

string

Alias
UMLS CUI 2011AA
C0009758
SNOMED CT 2011_0131
29445007
LOINC Version 232
MTHU009301
Sclera
Description

Sclerae

Data type

string

Alias
UMLS CUI 2011AA
C0036410
SNOMED CT 2011_0131
18619003
LOINC Version 232
MTHU015068
Extraocular muscles (EOM)
Description

EOM

Data type

string

Alias
UMLS CUI 2011AA
C0028863
SNOMED CT 2011_0131
67833000
LOINC Version 232
MTHU015037
Fundoscopy
Description

Funduscopic

Data type

string

Alias
UMLS CUI 2011AA
C0029090
SNOMED CT 2011_0131
274798009
MedDRA 14.1
10017519
Physical Exam - Ears, Nose, Throat
Description

Physical Exam - Ears, Nose, Throat

Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Description

Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.

Data type

boolean

EAR R ext canal
Description

EAR R ext canal

Data type

string

Alias
UMLS CUI 2011AA
C0013444
SNOMED CT 2011_0131
84301002
LOINC Version 232
MTHU015034
EAR R tympanic membrane (TM)
Description

EAR R tympanic membrane (TM)

Data type

string

Alias
UMLS CUI 2011AA
C0041445
SNOMED CT 2011_0131
42859004
LOINC Version 232
MTHU014731
EAR L ext canal
Description

EAR L ext canal

Data type

string

Alias
UMLS CUI 2011AA
C0013444
SNOMED CT 2011_0131
84301002
LOINC Version 232
MTHU015034
EAR L tympanic membrane (TM)
Description

EAR L tympanic membrane (TM)

Data type

string

Alias
UMLS CUI 2011AA
C0041445
SNOMED CT 2011_0131
42859004
LOINC Version 232
MTHU014731
Nasal septum, Septum nasi
Description

NOSE Septum

Data type

string

Alias
UMLS CUI 2011AA
C0027432
SNOMED CT 2011_0131
68426009
LOINC Version 232
MTHU015054
Nasal mucosa, Mucosa of nose
Description

Nose Mucosa

Data type

string

Alias
UMLS CUI 2011AA
C0027428
SNOMED CT 2011_0131
34508005
Nose R Nares
Description

Nose R Nares

Data type

string

Alias
UMLS CUI 2011AA
C0595944
SNOMED CT 2011_0131
1797002
LOINC Version 232
MTHU015056
Nose L Nares
Description

Nose L Nares

Data type

string

Alias
UMLS CUI 2011AA
C0595944
SNOMED CT 2011_0131
1797002
LOINC Version 232
MTHU015056
Mouth mucosa, Oral Mucosa
Description

Throat: Mouth mucosa

Data type

string

Alias
UMLS CUI 2011AA
C0026639
SNOMED CT 2011_0131
113277000
Pharynx, Throat
Description

Pharynx

Data type

string

Alias
UMLS CUI 2011AA
C0031354
SNOMED CT 2011_0131
54066008
LOINC Version 232
MTHU015061
Tonsils
Description

Tonsils

Data type

string

Alias
UMLS CUI 2011AA
C0836921
LOINC Version 232
MTHU015077
Dentition
Description

Dentition

Data type

string

Alias
UMLS CUI 2011AA
C0011443
SNOMED CT 2011_0131
245543004
LOINC Version 232
MTHU014794
Physical Exam - Neck
Description

Physical Exam - Neck

Neck, Collum, Cervical
Description

supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy

Data type

boolean

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Adenopathy
Description

Adenopathy

Data type

string

Alias
UMLS CUI 2011AA
C1706304
ICD-10-CM Version 2010
R59
Carotid bruit
Description

Carotid bruit

Data type

string

Alias
UMLS CUI 2011AA
C0007280
SNOMED CT 2011_0131
419642000
MedDRA 14.1
10048777
Jugular venous distension (JVD)
Description

JVD

Data type

string

Alias
UMLS CUI 2011AA
C1719935
SNOMED CT 2011_0131
422008005
Thyroid gland, Glandula thyroidea, thyroid
Description

Thyroid gland

Data type

string

Alias
UMLS CUI 2011AA
C0040132
SNOMED CT 2011_0131
69748006
LOINC Version 232
MTHU007792
Trachea, windpipe
Description

Trachea

Data type

string

Alias
UMLS CUI 2011AA
C0040578
SNOMED CT 2011_0131
44567001
LOINC Version 232
MTHU009117
Physical Exam - BREAST
Description

Physical Exam - BREAST

symmetric without masses
Description

symmetric without masses

Data type

boolean

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
inspection: Right breast
Description

inspection: Right breast

Data type

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
inspection: Right nipple
Description

inspection: Right nipple

Data type

string

Alias
UMLS CUI 2011AA
C0028109
SNOMED CT 2011_0131
24142002
inspection: Left breast
Description

inspection: Left breast

Data type

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
inspection: Left nipple
Description

inspection: Left nipple

Data type

string

Alias
UMLS CUI 2011AA
C0028109
SNOMED CT 2011_0131
24142002
palpation: Right breast
Description

palpation: Right breast

Data type

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
palpation: Right nipple
Description

palpation: Right nipple

Data type

string

Alias
UMLS CUI 2011AA
C0028109
SNOMED CT 2011_0131
24142002
palpation: Left breast
Description

palpation: Left breast

Data type

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
palpation: Left nipple
Description

palpation: Left nipple

Data type

string

Alias
UMLS CUI 2011AA
C0028109
SNOMED CT 2011_0131
24142002
Physical Exam - CHEST
Description

Physical Exam - CHEST

normal for inspection, percussion, palpation, and auscultation of the lungs.
Description

normal for inspection, percussion, palpation, and auscultation of the lungs.

Data type

boolean

Chest significant for:
Description

Chest significant for:

Data type

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Location
Description

Location

Data type

string

Alias
UMLS CUI 2011AA
C0450429
SNOMED CT 2011_0131
246267002
Additional lung sounds
Description

Additional lung sounds

Data type

string

Alias
UMLS CUI 2011AA
C0035234
SNOMED CT 2011_0131
52653008
MedDRA 14.1
10064779
Location
Description

Location

Data type

string

Alias
UMLS CUI 2011AA
C0450429
SNOMED CT 2011_0131
246267002
Physical Exam - HEART
Description

Physical Exam - HEART

PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Description

PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop

Data type

boolean

Alias
UMLS CUI 2011AA
C0018787
SNOMED CT 2011_0131
80891009
LOINC Version 232
MTHU001067
Palpation: PMI is
Description

Palpation: PMI is

Data type

string

Rhythm
Description

Rhythm

Data type

string

Heart Sounds: S1 is , S2 is, S3 is, S4 is
Description

Heart Sounds: S1 is , S2 is, S3 is, S4 is

Data type

string

Alias
UMLS CUI 2011AA
C0018820
SNOMED CT 2011_0131
23472005
PE HEART RUB TEXT
Description

PE HEART RUB TEXT

Data type

string

PE HEART OTHER SOUNDS TEXT
Description

PE HEART OTHER SOUNDS TEXT

Data type

string

Murmur: grade
Description

Murmur: grade

Data type

string

Alias
UMLS CUI 2011AA
C0018808
SNOMED CT 2011_0131
421493004
MedDRA 14.1
10007586
ICD-10-CM Version 2010
R01.1
ICD-9-CM Version 2011
785.2
Murmur heard best at
Description

Murmur heard best at

Data type

string

Murmur radiates
Description

Murmur radiates

Data type

string

Heart - OTHER1
Description

Heart - OTHER1

Data type

string

Physical Exam - VASCULAR
Description

Physical Exam - VASCULAR

Pulses present and equal bilat.
Description

Pulses present and equal bilat.

Data type

boolean

Aorta
Description

Aorta

Data type

string

Alias
UMLS CUI 2011AA
C0003483
SNOMED CT 2011_0131
15825003
LOINC Version 232
MTHU003021
Pulses R/L: carotid
Description

Pulses R/L: carotid

Data type

string

Alias
UMLS CUI 2011AA
C1096529
MedDRA 14.1
10053926
Pulses R/L: brachial
Description

Pulses R/L: brachial

Data type

string

Alias
UMLS CUI 2011AA
C1096531
MedDRA 14.1
10053929
Pulses R/L: radial
Description

Pulses R/L: radial

Data type

string

Alias
UMLS CUI 2011AA
C0232142
SNOMED CT 2011_0131
65452004
MedDRA 14.1
10053935
Pulses R/L: femoral
Description

Pulses R/L: femoral

Data type

string

Alias
UMLS CUI 2011AA
C0232148
SNOMED CT 2011_0131
67316000
MedDRA 14.1
10053932
Pulses R/L: popliteal
Description

Pulses R/L: popliteal

Data type

string

Alias
UMLS CUI 2011AA
C0232151
SNOMED CT 2011_0131
74828005
MedDRA 14.1
10053938
Pulses R/L: posterior tibial
Description

Pulses R/L: posterior tibial

Data type

string

Alias
UMLS CUI 2011AA
C1720310
SNOMED CT 2011_0131
421568004
Pulses R/L: dorsalis pedis
Description

Pulses R/L: dorsalis pedis

Data type

string

Alias
UMLS CUI 2011AA
C1706488
SNOMED CT 2011_0131
421811005
Physical Exam - ABDOMEN
Description

Physical Exam - ABDOMEN

soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Description

soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.

Data type

boolean

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Appearance
Description

Appearance

Data type

string

Bowel Sounds (BS), Borborygmi
Description

Bowel sounds

Data type

string

Alias
UMLS CUI 2011AA
C0232693
SNOMED CT 2011_0131
87042004
MedDRA 14.1
10006023
Midepigastric bruit
Description

Midepigastric bruit

Data type

string

Abdominal tenderness
Description

Abdominal tenderness

Data type

string

Alias
UMLS CUI 2011AA
C0232498
SNOMED CT 2011_0131
43478001
MedDRA 14.1
10000097
ICD-10-CM Version 2010
R10.81
ICD-9-CM Version 2011
789.6
Rebound
Description

Rebound

Data type

string

Liver, Hepar
Description

Liver

Data type

string

Alias
UMLS CUI 2011AA
C0023884
SNOMED CT 2011_0131
10200004
LOINC Version 232
MTHU002039
Spleen
Description

Spleen

Data type

string

Alias
UMLS CUI 2011AA
C0037993
SNOMED CT 2011_0131
78961009
LOINC Version 232
MTHU012104
Hernia
Description

Hernia

Data type

string

Alias
UMLS CUI 2011AA
C0019270
SNOMED CT 2011_0131
414403008
MedDRA 14.1
10019909
ICD-10-CM Version 2010
K40-K46
Physical Exam - GENITOURINARY/RECTAL: MALE
Description

Physical Exam - GENITOURINARY/RECTAL: MALE

GU Assessment
Description

GU Assessment

Data type

string

Alias
UMLS CUI 2011AA
C0042066
SNOMED CT 2011_0131
21514008
LOINC Version 232
MTHU013232
Urine appears
Description

Urine appears

Data type

string

Alias
UMLS CUI 2011AA
C0042036
SNOMED CT 2011_0131
78014005
LOINC Version 232
MTHU001343
Urine is adequate
Description

Urine is adequate

Data type

string

Alias
UMLS CUI 2011AA
C0042036
SNOMED CT 2011_0131
78014005
LOINC Version 232
MTHU001343
Urine output (UO), Urinary volume, Micturition volume
Description

Urine Output [ml]

Data type

integer

Alias
UMLS CUI 2011AA
C1287298
SNOMED CT 2011_0131
365678000
MedDRA 14.1
10059894
LOINC Version 232
MTHU024573
Foley catheter
Description

Foley catheter

Data type

string

Alias
UMLS CUI 2011AA
C0179804
MedDRA 14.1
10016892
Suprapubic catheter (SPC)
Description

Suprapubic catheter

Data type

string

Alias
UMLS CUI 2011AA
C0150798
SNOMED CT 2011_0131
286861005
scrotal contents
Description

scrotal contents

Data type

string

Penis
Description

Penis

Data type

string

Alias
UMLS CUI 2011AA
C0030851
SNOMED CT 2011_0131
18911002
LOINC Version 232
MTHU004206
rectal: sphincter tone
Description

rectal: sphincter tone

Data type

string

Haemorrhoids, Piles
Description

hemorrhoids

Data type

string

Alias
UMLS CUI 2011AA
C0019112
SNOMED CT 2011_0131
70153002
MedDRA 14.1
10019022
LOINC Version 232
MTHU015043
ICD-10-CM Version 2010
I84
ICD-9-CM Version 2011
455
CTCAE 1105E
E10773
Prostate, Prostate Gland
Description

Prostate

Data type

string

Alias
UMLS CUI 2011AA
C0033572
SNOMED CT 2011_0131
41216001
LOINC Version 232
MTHU004957
mass
Description

mass

Data type

string

Physical Exam - GENITOURINARY/RECTAL: FEMALE
Description

Physical Exam - GENITOURINARY/RECTAL: FEMALE

GU Assessment FEMALE
Description

GU Assessment FEMALE

Data type

string

Alias
UMLS CUI 2011AA
C0042066
SNOMED CT 2011_0131
21514008
LOINC Version 232
MTHU013232
Urine appears
Description

Urine appears

Data type

string

Alias
UMLS CUI 2011AA
C0042036
SNOMED CT 2011_0131
78014005
LOINC Version 232
MTHU001343
Urine is adequate
Description

Urine is adequate

Data type

string

Alias
UMLS CUI 2011AA
C0042036
SNOMED CT 2011_0131
78014005
LOINC Version 232
MTHU001343
Urine Output [ml]
Description

Urine Output [ml]

Data type

integer

Alias
UMLS CUI 2011AA
C1287298
SNOMED CT 2011_0131
365678000
MedDRA 14.1
10059894
LOINC Version 232
MTHU024573
Foley catheter
Description

Foley catheter

Data type

string

Alias
UMLS CUI 2011AA
C0179804
MedDRA 14.1
10016892
Suprapubic catheter (SPC)
Description

Suprapubic catheter

Data type

string

Alias
UMLS CUI 2011AA
C0150798
SNOMED CT 2011_0131
286861005
External genitalia
Description

External genitalia

Data type

string

Alias
UMLS CUI 2011AA
C0227605
SNOMED CT 2011_0131
77142006
Urethra
Description

Urethra

Data type

string

Alias
UMLS CUI 2011AA
C0041967
SNOMED CT 2011_0131
264255005
LOINC Version 232
MTHU001321
Vagina
Description

Vagina

Data type

string

Alias
UMLS CUI 2011AA
C0042232
SNOMED CT 2011_0131
76784001
LOINC Version 232
MTHU014732
Urinary Bladder
Description

Bladder

Data type

string

Alias
UMLS CUI 2011AA
C0005682
SNOMED CT 2011_0131
89837001
LOINC Version 232
MTHU002918
Cervix uteri
Description

Cervix

Data type

string

Alias
UMLS CUI 2011AA
C0007874
SNOMED CT 2011_0131
71252005
LOINC Version 232
MTHU001800
Uterus
Description

Uterus

Data type

string

Alias
UMLS CUI 2011AA
C0042149
SNOMED CT 2011_0131
35039007
LOINC Version 232
MTHU002943
Uterine adnexa
Description

adnexa

Data type

string

Alias
UMLS CUI 2011AA
C0001575
SNOMED CT 2011_0131
23043003
LOINC Version 232
MTHU015033
rectal: sphincter tone
Description

rectal: sphincter tone

Data type

string

Haemorrhoids, Piles
Description

hemorrhoids

Data type

string

Alias
UMLS CUI 2011AA
C0019112
SNOMED CT 2011_0131
70153002
MedDRA 14.1
10019022
LOINC Version 232
MTHU015043
ICD-10-CM Version 2010
I84
ICD-9-CM Version 2011
455
CTCAE 1105E
E10773
mass
Description

mass

Data type

string

Physical Exam -MUSCULOSKELETAL
Description

Physical Exam -MUSCULOSKELETAL

Musculoskeletal System, Musculo-skeletal system
Description

MUSCULOSKELETAL

Data type

string

Alias
UMLS CUI 2011AA
C0026860
SNOMED CT 2011_0131
26107004
LOINC Version 232
MTHU001411
Gait, Manner of walking
Description

Gait

Data type

string

Alias
UMLS CUI 2011AA
C0016928
SNOMED CT 2011_0131
63448001
LOINC Version 232
MTHU015039
Station
Description

Station

Data type

string

Digits
Description

Digits

Data type

string

Alias
UMLS CUI 2011AA
C0582802
SNOMED CT 2011_0131
82680008
LOINC Version 232
MTHU015035
Nails
Description

Nails

Data type

string

Alias
UMLS CUI 2011AA
C0027342
SNOMED CT 2011_0131
72651009
LOINC Version 232
MTHU002041
Joints, Bones, Muscles
Description

Joints, Bones, Muscles

Data type

text

Alias
SNOMED CT 2011_0131
39352004, 272673000, 71616004
UMLS CUI-1
C0022417
UMLS CUI-2
C0262950
UMLS CUI-3
C0026845
Head & Neck (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Head & Neck (inspection & palpation, ROM, stability, muscle strength, tone)

Data type

text

Alias
SNOMED CT 2011_0131
69536005, 45048000
UMLS CUI-1
C0018670
UMLS CUI-2
C0027530
Spine/Ribs/Pelvis (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Spine/Ribs/Pelvis

Data type

string

Right Shoulder (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Right Shoulder

Data type

string

Alias
UMLS CUI 2011AA
C0037004
SNOMED CT 2011_0131
16982005
LOINC Version 232
MTHU002689
Right Elbow (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Right Elbow

Data type

string

Alias
UMLS CUI 2011AA
C0013769
SNOMED CT 2011_0131
127949000
LOINC Version 232
MTHU002674
Right Wrist (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Right Wrist

Data type

string

Alias
UMLS CUI 2011AA
C0043262
SNOMED CT 2011_0131
8205005
LOINC Version 232
MTHU002691
Left Shoulder (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Left Shoulder

Data type

string

Alias
UMLS CUI 2011AA
C0037004
SNOMED CT 2011_0131
16982005
LOINC Version 232
MTHU002689
Left Elbow (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Left Elbow

Data type

string

Alias
UMLS CUI 2011AA
C0013769
SNOMED CT 2011_0131
127949000
LOINC Version 232
MTHU002674
Left Wrist (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Left Wrist

Data type

string

Alias
UMLS CUI 2011AA
C0043262
SNOMED CT 2011_0131
8205005
LOINC Version 232
MTHU002691
Right Hip (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Right Hip

Data type

string

Alias
UMLS CUI 2011AA
C0019552
SNOMED CT 2011_0131
24136001
LOINC Version 232
MTHU002686
Right Knee (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Right Knee

Data type

string

Alias
UMLS CUI 2011AA
C0022742
SNOMED CT 2011_0131
304679005
LOINC Version 232
MTHU002687
Right Ankle (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Right Ankle

Data type

string

Alias
UMLS CUI 2011AA
C0003086
SNOMED CT 2011_0131
344001
Left Hip (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Left Hip

Data type

string

Alias
UMLS CUI 2011AA
C0019552
SNOMED CT 2011_0131
24136001
LOINC Version 232
MTHU002686
Left Knee (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Left Knee

Data type

string

Alias
UMLS CUI 2011AA
C0022742
SNOMED CT 2011_0131
304679005
LOINC Version 232
MTHU002687
Left Ankle (inspection & palpation, ROM, stability, muscle strength, tone)
Description

Left Ankle

Data type

string

Alias
UMLS CUI 2011AA
C0003086
SNOMED CT 2011_0131
344001
Physical Exam - EXTREMITIES
Description

Physical Exam - EXTREMITIES

Significant for:
Description

Significant for:

Data type

string

Pitting edema
Description

pitting edema

Data type

string

Alias
UMLS CUI 2011AA
C0333243
SNOMED CT 2011_0131
139248000
pretibial: R / L
Description

pretibial: R / L

Data type

string

ankle: R / L
Description

ankle: R / L

Data type

string

Alias
UMLS CUI 2011AA
C0003086
SNOMED CT 2011_0131
344001
foot: R / L
Description

foot: R / L

Data type

string

Alias
UMLS CUI 2011AA
C0016504
SNOMED CT 2011_0131
56459004
LOINC Version 232
MTHU002679
Posterior tibial pulse R/L
Description

Pulses R/L: posterior tibial

Data type

string

Alias
UMLS CUI 2011AA
C1720310
SNOMED CT 2011_0131
421568004
Pulses R/L: dorsalis pedis
Description

Pulses R/L: dorsalis pedis

Data type

string

Alias
UMLS CUI 2011AA
C1706488
SNOMED CT 2011_0131
421811005
capillary fill time R/L
Description

capillary fill time R/L

Data type

string

sensation by monofilament test R/L
Description

sensation by monofilament test R/L

Data type

string

toenails
Description

toenails

Data type

string

skin
Description

skin

Data type

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Physical Exam - LYMPHATIC
Description

Physical Exam - LYMPHATIC

no adenopathy
Description

no adenopathy

Data type

boolean

adenopathy (generalized, localized)
Description

adenopathy

Data type

string

Alias
UMLS CUI 2011AA
C1706304
Neck, Collum, Cervical
Description

neck

Data type

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Axilla, axillary region
Description

Axilla

Data type

string

Alias
UMLS CUI 2011AA
C0004454
SNOMED CT 2011_0131
91470000
LOINC Version 232
MTHU002668
Inguinal region
Description

groin

Data type

string

Alias
UMLS CUI 2011AA
C0018246
SNOMED CT 2011_0131
26893007
LOINC Version 232
MTHU002684
other
Description

other

Data type

string

Physical Exam - SKIN
Description

Physical Exam - SKIN

Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Description

Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.

Data type

boolean

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
inspection, visual examination
Description

inspection

Data type

string

Alias
UMLS CUI 2011AA
C0199219
SNOMED CT 2011_0131
32750006
Palpation
Description

Palpation

Data type

string

Alias
UMLS CUI 2011AA
C0030247
SNOMED CT 2011_0131
113011001
Physical Exam - Wound and Incision Care
Description

Physical Exam - Wound and Incision Care

Wound
Description

WOUND #

Data type

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
WOUND LOCATION
Description

WOUND LOCATION

Data type

string

WOUND MEASUREMENT (Length, Width, Depth [cm])
Description

WOUND MEASUREMENT (Length, Width, Depth [cm])

Data type

string

UNDERMINING Wound
Description

UNDERMINING Wound

Data type

boolean

TUNNELING Wound
Description

TUNNELING Wound

Data type

boolean

SURROUNDING SKIN: WOUND BASE
Description

SURROUNDING SKIN: WOUND BASE

Data type

string

Sensation, Esthesia, Sensory function, Sensory perception
Description

SENSATION

Data type

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
EXUDATE
Description

EXUDATE

Data type

string

Alias
UMLS CUI 2011AA
C0015388
SNOMED CT 2011_0131
247450001
LOINC Version 232
MTHU025016
COLOR OF DRAINAGE
Description

COLOR OF DRAINAGE

Data type

string

ODOR: Before Cleaning
Description

ODOR: Before Cleaning

Data type

boolean

ODOR: After Cleaning
Description

ODOR: After Cleaning

Data type

boolean

CLEANSED WITH/IRRIGATED WITH
Description

CLEANSED WITH/IRRIGATED WITH

Data type

string

WOUND MED applied
Description

WOUND MED applied

Data type

string

FILLED WITH
Description

FILLED WITH

Data type

string

COVERED WITH
Description

COVERED WITH

Data type

string

SECURED WITH
Description

SECURED WITH

Data type

string

PRESSURE RELIEF
Description

PRESSURE RELIEF

Data type

string

COMMENTS
Description

COMMENTS

Data type

string

PHOTOGRAPH DATE
Description

PHOTOGRAPH DATE

Data type

date

NARRATIVE
Description

NARRATIVE

Data type

string

Alias
UMLS CUI 2011AA
C1135957
Surgical incision
Description

INCISION #

Data type

string

Alias
UMLS CUI 2011AA
C0184898
SNOMED CT 2011_0131
34896006
Location
Description

LOCATION

Data type

string

Alias
UMLS CUI 2011AA
C0450429
SNOMED CT 2011_0131
246267002
CLOSURE TYPE
Description

CLOSURE TYPE

Data type

string

DRESSING TYPE
Description

DRESSING TYPE

Data type

string

DRESSING APPEARANCE
Description

DRESSING APPEARANCE

Data type

string

Drains, Drain device
Description

DRAINS

Data type

string

Alias
UMLS CUI 2011AA
C0180499
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
NARRATIVE
Description

NARRATIVE

Data type

string

Alias
UMLS CUI 2011AA
C1135957
Physical Exam - NEUROLOGIC
Description

Physical Exam - NEUROLOGIC

Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Description

Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements

Data type

boolean

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
Consciousness related finding
Description

Conciousness

Data type

string

Alias
UMLS CUI 2011AA
C0234421
SNOMED CT 2011_0131
106167005
Responsive to
Description

Responsive to

Data type

string

Orientation as to time, place and people
Description

Orientation

Data type

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
Proverb
Description

Proverb

Data type

string

Writing
Description

Writing

Data type

string

Alias
UMLS CUI 2011AA
C2584304
SNOMED CT 2011_0131
12261009
Reading (activity)
Description

Reading

Data type

string

Alias
UMLS CUI 2011AA
C0034754
SNOMED CT 2011_0131
50360004
Memory function
Description

Memory

Data type

string

Alias
UMLS CUI 2011AA
C0025260
SNOMED CT 2011_0131
303116000
LOINC Version 232
MTHU021129
Registration
Description

Registration

Data type

string

Naming Intact
Description

Naming Intact

Data type

string

Speech, Speaking, using verbal communication
Description

Speech

Data type

string

Alias
UMLS CUI 2011AA
C0037817
SNOMED CT 2011_0131
87335007
LOINC Version 232
MTHU021528
OTHER
Description

OTHER

Data type

string

Score normal
Description

Score normal

Data type

boolean

Concentration normal
Description

Concentration normal

Data type

boolean

Cranial nerves normal
Description

Cranial nerves normal

Data type

boolean

Comment
Description

Comment

Data type

string

Muscle Tonus, Muscle tone, Muscle tension
Description

Motor tone

Data type

string

Alias
UMLS CUI 2011AA
C0026841
MedDRA 14.1
10070541
LOINC Version 232
MTHU015024
Muscle Strength R/L
Description

Motor strength R/L

Data type

string

Alias
UMLS CUI 2011AA
C0517349
Grip R/L
Description

Grip R/L

Data type

string

Alias
UMLS CUI 2011AA
C0220843
Biceps brachii, Biceps brachii muscle
Description

Biceps R/L

Data type

string

Alias
UMLS CUI 2011AA
C0559499
SNOMED CT 2011_0131
16225001
LOINC Version 232
MTHU014778
Triceps brachii muscle, Triceps brachii
Description

Triceps R/L

Data type

string

Alias
UMLS CUI 2011AA
C0559502
SNOMED CT 2011_0131
40284004
LOINC Version 232
MTHU014783
Quadriceps femoris muscle, Quadriceps femoris
Description

Quadriceps R/L

Data type

string

Alias
UMLS CUI 2011AA
C0224440
SNOMED CT 2011_0131
21989003
Hip Extensors R/L
Description

Hip Extensors R/L

Data type

string

Dorsiflexion R/L
Description

Dorsiflexion R/L

Data type

string

Plantarflexion R/L
Description

Plantarflexion R/L

Data type

string

Sensation, Esthesia, Sensory function, Sensory perception
Description

Sensation

Data type

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
Pin prick sensation, Discrimination between sharp and blunt
Description

Pin prick

Data type

string

Alias
UMLS CUI 2011AA
C0423557
SNOMED CT 2011_0131
247315008
Comment
Description

Comment

Data type

string

Light touch
Description

Light touch

Data type

string

Vibration
Description

Vibration

Data type

string

Alias
UMLS CUI 2011AA
C0459800
SNOMED CT 2011_0131
33679000
LOINC Version 232
MTHU021537
Comment
Description

Comment

Data type

string

Position Sense, Position sensation, Postural sense
Description

Position Sense

Data type

string

Alias
UMLS CUI 2011AA
C0234219
SNOMED CT 2011_0131
73535003
Temperature
Description

Temperature

Data type

string

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
Stereognosis, Stereognostic perception, Touch discrimination
Description

Stereognosis

Data type

string

Alias
UMLS CUI 2011AA
C0038263
SNOMED CT 2011_0131
22382001
Biceps reflex R/L
Description

Deep Tendon Reflexes Biceps R/L

Data type

string

Alias
UMLS CUI 2011AA
C0234151
SNOMED CT 2011_0131
30901003
Triceps reflex R/L
Description

Deep Tendon Reflexes Triceps R/L

Data type

string

Alias
UMLS CUI 2011AA
C0422908
SNOMED CT 2011_0131
271716008
Deep Tendon Reflexes Brachioradialis R/L
Description

Deep Tendon Reflexes Brachioradialis R/L

Data type

string

Patellar reflex, Knee reflex, Quadriceps reflex, Knee jerk (KJ) R/L
Description

Deep Tendon Reflexes Patellar R/L

Data type

string

Alias
UMLS CUI 2011AA
C0234147
SNOMED CT 2011_0131
271714006
Deep Tendon Reflexes Achilles R/L
Description

Deep Tendon Reflexes Achilles R/L

Data type

string

Abnormal reflexes
Description

Abnormal reflexes

Data type

string

Alias
UMLS CUI 2011AA
C0034933
SNOMED CT 2011_0131
46670006
MedDRA 14.1
10000171
ICD-10-CM Version 2010
R29.2
ICD-9-CM Version 2011
796.1
Involuntary Movements
Description

Involuntary Movements

Data type

string

Alias
UMLS CUI 2011AA
C0427086
SNOMED CT 2011_0131
267078001
MedDRA 14.1
10028042
CTCAE 1105E
E12728
Cerebellar Signs
Description

Cerebellar Signs

Data type

string

Alias
UMLS CUI 2011AA
C0742038
Gait, Manner of walking
Description

Gait

Data type

string

Alias
UMLS CUI 2011AA
C0016928
SNOMED CT 2011_0131
63448001
LOINC Version 232
MTHU015039
Comment
Description

Comment

Data type

string

Station
Description

Station

Data type

string

PSYCHIATRIC
Description

PSYCHIATRIC

Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Description

Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.

Data type

boolean

Judgement & Insight
Description

Judgement & Insight

Data type

text

Alias
SNOMED CT 2011_0131
61254005, 27026000
UMLS CUI-1
C0022423
UMLS CUI-2
C0233820
Orientation as to time, place and people
Description

Orientation

Data type

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
Recent Memory
Description

Recent Memory

Data type

string

Alias
UMLS CUI 2011AA
C0233792
SNOMED CT 2011_0131
69063000
Remote Memory, Palinmnesis
Description

Remote Memory

Data type

string

Alias
UMLS CUI 2011AA
C0233793
SNOMED CT 2011_0131
81964002
Mood/Affect
Description

Mood/Affect

Data type

text

Alias
SNOMED CT 2011_0131
85256008, 4065008
LOINC Version 232
MTHU031584
UMLS CUI-1
C0026516
UMLS CUI-2
C0001721
Laboratory Results
Description

Laboratory Results

Laboratory results reviewed
Description

Laboratory results reviewed

Data type

boolean

Prior 24 hour labs
Description

Prior 24 hour labs

Data type

string

Alias
UMLS CUI 2011AA
C0587081
SNOMED CT 2011_0131
118246004
Other
Description

Other

Data type

string

Radiology Results
Description

Radiology Results

Radiology results reviewed
Description

Radiology results reviewed

Data type

boolean

Radiology report
Description

radiology findings

Data type

string

Alias
UMLS CUI 2011AA
C1299496
SNOMED CT 2011_0131
371527006
ASSESSMENT
Description

ASSESSMENT

acceptable for surgery
Description

acceptable for surgery

Data type

boolean

progressing well
Description

progressing well

Data type

boolean

stable medically
Description

stable medically

Data type

boolean

Alias
UMLS CUI 2011AA
C0205360
SNOMED CT 2011_0131
58158008
LOINC Version 232
MTHU015276
Active Problems
Description

Active Problems

Data type

string

Alias
UMLS CUI 2011AA
C0552582
LOINC Version 232
LP73189-0
Other
Description

Other

Data type

string

PLAN
Description

PLAN

Continue Home Regimen
Description

Continue Home Regimen

Data type

boolean

Continue Home Meds
Description

Continue Home Meds

Data type

boolean

Continue Chemotherapy
Description

Continue Chemotherapy

Data type

boolean

Continue IV Antibiotics
Description

Continue IV Antibiotics

Data type

boolean

Continue PO Antibiotics
Description

Continue PO Antibiotics

Data type

boolean

Deep venous thrombosis prophylaxis
Description

DVT Prophylaxis

Data type

boolean

Alias
UMLS CUI 2011AA
C0853245
MedDRA 14.1
10013880
O2 Protocol
Description

O2 Protocol

Data type

boolean

Follow Up X-Rays
Description

Follow Up X-Rays

Data type

boolean

UTI treatment
Description

UTI treatment

Data type

boolean

Alias
UMLS CUI 2011AA
C0042029
SNOMED CT 2011_0131
68566005
MedDRA 14.1
10046577
Monitor Blood Pressure and Heart Rate
Description

Monitor Blood Pressure and Heart Rate

Data type

boolean

Monitor Diabetes Mellitus
Description

Monitor Diabetes Mellitus

Data type

boolean

Accuchecks AC & HS
Description

Accuchecks AC & HS

Data type

boolean

Accuchecks Q6H
Description

Accuchecks Q6H

Data type

boolean

Sliding Scale Regular Insulin
Description

Sliding Scale Regular Insulin

Data type

boolean

Alias
UMLS CUI 2011AA
C0021641
SNOMED CT 2011_0131
67866001
LOINC Version 232
MTHU019392
Check Follow Up Labs
Description

Check Follow Up Labs

Data type

boolean

Appreciate following patient with you
Description

Appreciate following patient with you

Data type

boolean

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Similar models

HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
H and P or consult specialty
Reason for visit
Item
Reason for visit
string
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
Item Group
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
SOURCE(S) OF HISTORY
Item
SOURCE(S) OF HISTORY (Patient, Family, Outside records, Unobtainable)
integer
SOURCE(S) OF HISTORY comment
Item
SOURCE(S) OF HISTORY comment
string
Item Group
REVIEW OF SYSTEMS
REVIEW OF SYSTEMS: see form Review of systems
Item
REVIEW OF SYSTEMS: see form Review of systems
string
Item Group
PAST HISTORY
Adult Illness
Item
Adult disease
string
C0277562 (UMLS CUI 2011AA)
64342008 (SNOMED CT 2011_0131)
History of childhood diseases
Item
Childhood Illness
string
C0489532 (UMLS CUI 2011AA)
MTHU001066 (LOINC Version 232)
Surgeries
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Injury
Item
Traumatic injury, trauma
string
C0175677 (UMLS CUI 2011AA)
417746004 (SNOMED CT 2011_0131)
10022116 (MedDRA 14.1)
T14.9 (ICD-10-CM Version 2010)
Item Group
Female Specific History
Date of last menstrual period
Item
Date of last menstrual period (LMP)
date
C0425932 (UMLS CUI 2011AA)
21840007 (SNOMED CT 2011_0131)
MTHU024536 (LOINC Version 232)
Date of last PAP
Item
Date of last Papanicolaou test (PAP)
date
last PAP Results
Item
Pap smear, smear cervix, vaginal smear, Papanicolaou Test
string
C0079104 (UMLS CUI 2011AA)
10041205 (MedDRA 14.1)
Date of last MMG
Item
Date of last mammogram (MMG)
date
last MMG Results
Item
Mammogram
string
C0024671 (UMLS CUI 2011AA)
71651007 (SNOMED CT 2011_0131)
10026735 (MedDRA 14.1)
Age at menarche
Item
Age at menarche
integer
C1314691 (UMLS CUI 2011AA)
398700009 (SNOMED CT 2011_0131)
MTHU018825 (LOINC Version 232)
Describe Menses
Item
Menstruation, Menses
string
C0025344 (UMLS CUI 2011AA)
248957007 (SNOMED CT 2011_0131)
Birth Control
Item
Contraception, Birth control
string
C0700589 (UMLS CUI 2011AA)
146680009 (SNOMED CT 2011_0131)
10010808 (MedDRA 14.1)
Pregnancies
Item
Pregnancy, Gestation
string
C0032961 (UMLS CUI 2011AA)
289908002 (SNOMED CT 2011_0131)
10036556 (MedDRA 14.1)
MTHU035048 (LOINC Version 232)
Abortions
Item
Abortion, Pregnancy with abortive outcome
string
C0156543 (UMLS CUI 2011AA)
70317007 (SNOMED CT 2011_0131)
10000210 (MedDRA 14.1)
MTHU002834 (LOINC Version 232)
O00-O08 (ICD-10-CM Version 2010)
637 (ICD-9-CM Version 2011)
Number of full term pregnancies
Item
Number of full term pregnancies
integer
Number of spontaneous abortions
Item
Number of spontaneous abortions
integer
Number of therapeutic abortions
Item
Number of therapeutic abortions
integer
Number of other types Abortions
Item
Number of other types Abortions
integer
Age at first pregnancy
Item
Age at first pregnancy
integer
Item Group
FAMILY HISTORY
Family history: see form Family Hx
Item
Family history (FH)
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
Item Group
SOCIAL HISTORY
Social history: see form Social History
Item
Social and personal history, Social and personal circumstances
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
Item Group
ALLERGIES
No Known Allergies
Item
No Known Allergies
boolean
Allergies text
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
Item Group
MEDICATIONS
Inpatient medications
Item
Inpatient Medications
string
C0013227 (UMLS CUI 2011AA)
Active medications
Item
current medication list, active medication
string
C1553892 (UMLS CUI 2011AA)
Home medications
Item
Home Medications
string
C0013227 (UMLS CUI 2011AA)
Item Group
PHYSICAL EXAM - General
VITALS
Item
VITAL signs
string
C0518766 (UMLS CUI 2011AA)
46680005 (SNOMED CT 2011_0131)
MTHU024540 (LOINC Version 232)
Temperature
Item
Temperature
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulse
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Respiration rate, Breathing rate (BR)
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blood pressure (BP)
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
Pain
Item
Pain
string
C0030193 (UMLS CUI 2011AA)
22253000 (SNOMED CT 2011_0131)
10033371 (MedDRA 14.1)
MTHU029813 (LOINC Version 232)
R52 (ICD-10-CM Version 2010)
338-338.9 (ICD-9-CM Version 2011)
E11167 (CTCAE 1105E)
Weight
Item
Body weight
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
GENERAL
Item
GENERAL
text
C1148438 (UMLS CUI-1)
Item Group
PHYSICAL EXAM - HEAD
HEAD
Item
HEAD (Normocephalic, atraumatic)
boolean
Head text (significant for:)
Item
Head
string
C0018670 (UMLS CUI 2011AA)
69536005 (SNOMED CT 2011_0131)
MTHU001435 (LOINC Version 232)
Item Group
PHYSICAL EXAM - EYES
EYES
Item
EYES (Pupils are RRE and react to light and accomodation, Conjunctivae pink and moist, Extraocular muscles intact)
boolean
C0015392 (UMLS CUI 2011AA)
81745001 (SNOMED CT 2011_0131)
MTHU000064 (LOINC Version 232)
Pupils
Item
Pupil
string
C0034121 (UMLS CUI 2011AA)
392406005 (SNOMED CT 2011_0131)
MTHU015063 (LOINC Version 232)
Conjunctivae
Item
conjunctiva
string
C0009758 (UMLS CUI 2011AA)
29445007 (SNOMED CT 2011_0131)
MTHU009301 (LOINC Version 232)
Sclerae
Item
Sclera
string
C0036410 (UMLS CUI 2011AA)
18619003 (SNOMED CT 2011_0131)
MTHU015068 (LOINC Version 232)
EOM
Item
Extraocular muscles (EOM)
string
C0028863 (UMLS CUI 2011AA)
67833000 (SNOMED CT 2011_0131)
MTHU015037 (LOINC Version 232)
Funduscopic
Item
Fundoscopy
string
C0029090 (UMLS CUI 2011AA)
274798009 (SNOMED CT 2011_0131)
10017519 (MedDRA 14.1)
Item Group
Physical Exam - Ears, Nose, Throat
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Item
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
boolean
EAR R ext canal
Item
EAR R ext canal
string
C0013444 (UMLS CUI 2011AA)
84301002 (SNOMED CT 2011_0131)
MTHU015034 (LOINC Version 232)
EAR R tympanic membrane (TM)
Item
EAR R tympanic membrane (TM)
string
C0041445 (UMLS CUI 2011AA)
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
EAR L ext canal
Item
EAR L ext canal
string
C0013444 (UMLS CUI 2011AA)
84301002 (SNOMED CT 2011_0131)
MTHU015034 (LOINC Version 232)
EAR L tympanic membrane (TM)
Item
EAR L tympanic membrane (TM)
string
C0041445 (UMLS CUI 2011AA)
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
NOSE Septum
Item
Nasal septum, Septum nasi
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Nose Mucosa
Item
Nasal mucosa, Mucosa of nose
string
C0027428 (UMLS CUI 2011AA)
34508005 (SNOMED CT 2011_0131)
Nose R Nares
Item
Nose R Nares
string
C0595944 (UMLS CUI 2011AA)
1797002 (SNOMED CT 2011_0131)
MTHU015056 (LOINC Version 232)
Nose L Nares
Item
Nose L Nares
string
C0595944 (UMLS CUI 2011AA)
1797002 (SNOMED CT 2011_0131)
MTHU015056 (LOINC Version 232)
Throat: Mouth mucosa
Item
Mouth mucosa, Oral Mucosa
string
C0026639 (UMLS CUI 2011AA)
113277000 (SNOMED CT 2011_0131)
Pharynx
Item
Pharynx, Throat
string
C0031354 (UMLS CUI 2011AA)
54066008 (SNOMED CT 2011_0131)
MTHU015061 (LOINC Version 232)
Tonsils
Item
Tonsils
string
C0836921 (UMLS CUI 2011AA)
MTHU015077 (LOINC Version 232)
Dentition
Item
Dentition
string
C0011443 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU014794 (LOINC Version 232)
Item Group
Physical Exam - Neck
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Item
Neck, Collum, Cervical
boolean
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Adenopathy
Item
Adenopathy
string
C1706304 (UMLS CUI 2011AA)
R59 (ICD-10-CM Version 2010)
Carotid bruit
Item
Carotid bruit
string
C0007280 (UMLS CUI 2011AA)
419642000 (SNOMED CT 2011_0131)
10048777 (MedDRA 14.1)
JVD
Item
Jugular venous distension (JVD)
string
C1719935 (UMLS CUI 2011AA)
422008005 (SNOMED CT 2011_0131)
Thyroid gland
Item
Thyroid gland, Glandula thyroidea, thyroid
string
C0040132 (UMLS CUI 2011AA)
69748006 (SNOMED CT 2011_0131)
MTHU007792 (LOINC Version 232)
Trachea
Item
Trachea, windpipe
string
C0040578 (UMLS CUI 2011AA)
44567001 (SNOMED CT 2011_0131)
MTHU009117 (LOINC Version 232)
Item Group
Physical Exam - BREAST
symmetric without masses
Item
symmetric without masses
boolean
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
inspection: Right breast
Item
inspection: Right breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
inspection: Right nipple
Item
inspection: Right nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
inspection: Left breast
Item
inspection: Left breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
inspection: Left nipple
Item
inspection: Left nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
palpation: Right breast
Item
palpation: Right breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
palpation: Right nipple
Item
palpation: Right nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
palpation: Left breast
Item
palpation: Left breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
palpation: Left nipple
Item
palpation: Left nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
Item Group
Physical Exam - CHEST
normal for inspection, percussion, palpation, and auscultation of the lungs.
Item
normal for inspection, percussion, palpation, and auscultation of the lungs.
boolean
Chest significant for:
Item
Chest significant for:
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
Location
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
Additional lung sounds
Item
Additional lung sounds
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
Location
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
Item Group
Physical Exam - HEART
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Item
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
boolean
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
Palpation: PMI is
Item
Palpation: PMI is
string
Rhythm
Item
Rhythm
string
Heart Sounds: S1 is , S2 is, S3 is, S4 is
Item
Heart Sounds: S1 is , S2 is, S3 is, S4 is
string
C0018820 (UMLS CUI 2011AA)
23472005 (SNOMED CT 2011_0131)
PE HEART RUB TEXT
Item
PE HEART RUB TEXT
string
PE HEART OTHER SOUNDS TEXT
Item
PE HEART OTHER SOUNDS TEXT
string
Murmur: grade
Item
Murmur: grade
string
C0018808 (UMLS CUI 2011AA)
421493004 (SNOMED CT 2011_0131)
10007586 (MedDRA 14.1)
R01.1 (ICD-10-CM Version 2010)
785.2 (ICD-9-CM Version 2011)
Murmur heard best at
Item
Murmur heard best at
string
Murmur radiates
Item
Murmur radiates
string
Heart - OTHER1
Item
Heart - OTHER1
string
Item Group
Physical Exam - VASCULAR
Pulses present and equal bilat.
Item
Pulses present and equal bilat.
boolean
Aorta
Item
Aorta
string
C0003483 (UMLS CUI 2011AA)
15825003 (SNOMED CT 2011_0131)
MTHU003021 (LOINC Version 232)
Pulses R/L: carotid
Item
Pulses R/L: carotid
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
Pulses R/L: brachial
Item
Pulses R/L: brachial
string
C1096531 (UMLS CUI 2011AA)
10053929 (MedDRA 14.1)
Pulses R/L: radial
Item
Pulses R/L: radial
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pulses R/L: femoral
Item
Pulses R/L: femoral
string
C0232148 (UMLS CUI 2011AA)
67316000 (SNOMED CT 2011_0131)
10053932 (MedDRA 14.1)
Pulses R/L: popliteal
Item
Pulses R/L: popliteal
string
C0232151 (UMLS CUI 2011AA)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
Pulses R/L: posterior tibial
Item
Pulses R/L: posterior tibial
string
C1720310 (UMLS CUI 2011AA)
421568004 (SNOMED CT 2011_0131)
Pulses R/L: dorsalis pedis
Item
Pulses R/L: dorsalis pedis
string
C1706488 (UMLS CUI 2011AA)
421811005 (SNOMED CT 2011_0131)
Item Group
Physical Exam - ABDOMEN
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Item
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
boolean
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
Appearance
Item
Appearance
string
Bowel sounds
Item
Bowel Sounds (BS), Borborygmi
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
Midepigastric bruit
Item
Midepigastric bruit
string
Abdominal tenderness
Item
Abdominal tenderness
string
C0232498 (UMLS CUI 2011AA)
43478001 (SNOMED CT 2011_0131)
10000097 (MedDRA 14.1)
R10.81 (ICD-10-CM Version 2010)
789.6 (ICD-9-CM Version 2011)
Rebound
Item
Rebound
string
Liver
Item
Liver, Hepar
string
C0023884 (UMLS CUI 2011AA)
10200004 (SNOMED CT 2011_0131)
MTHU002039 (LOINC Version 232)
Spleen
Item
Spleen
string
C0037993 (UMLS CUI 2011AA)
78961009 (SNOMED CT 2011_0131)
MTHU012104 (LOINC Version 232)
Hernia
Item
Hernia
string
C0019270 (UMLS CUI 2011AA)
414403008 (SNOMED CT 2011_0131)
10019909 (MedDRA 14.1)
K40-K46 (ICD-10-CM Version 2010)
Item Group
Physical Exam - GENITOURINARY/RECTAL: MALE
GU Assessment
Item
GU Assessment
string
C0042066 (UMLS CUI 2011AA)
21514008 (SNOMED CT 2011_0131)
MTHU013232 (LOINC Version 232)
Urine appears
Item
Urine appears
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine is adequate
Item
Urine is adequate
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine Output [ml]
Item
Urine output (UO), Urinary volume, Micturition volume
integer
C1287298 (UMLS CUI 2011AA)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
Foley catheter
Item
Foley catheter
string
C0179804 (UMLS CUI 2011AA)
10016892 (MedDRA 14.1)
Suprapubic catheter
Item
Suprapubic catheter (SPC)
string
C0150798 (UMLS CUI 2011AA)
286861005 (SNOMED CT 2011_0131)
scrotal contents
Item
scrotal contents
string
Penis
Item
Penis
string
C0030851 (UMLS CUI 2011AA)
18911002 (SNOMED CT 2011_0131)
MTHU004206 (LOINC Version 232)
rectal: sphincter tone
Item
rectal: sphincter tone
string
hemorrhoids
Item
Haemorrhoids, Piles
string
C0019112 (UMLS CUI 2011AA)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
Prostate
Item
Prostate, Prostate Gland
string
C0033572 (UMLS CUI 2011AA)
41216001 (SNOMED CT 2011_0131)
MTHU004957 (LOINC Version 232)
mass
Item
mass
string
Item Group
Physical Exam - GENITOURINARY/RECTAL: FEMALE
GU Assessment FEMALE
Item
GU Assessment FEMALE
string
C0042066 (UMLS CUI 2011AA)
21514008 (SNOMED CT 2011_0131)
MTHU013232 (LOINC Version 232)
Urine appears
Item
Urine appears
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine is adequate
Item
Urine is adequate
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine Output [ml]
Item
Urine Output [ml]
integer
C1287298 (UMLS CUI 2011AA)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
Foley catheter
Item
Foley catheter
string
C0179804 (UMLS CUI 2011AA)
10016892 (MedDRA 14.1)
Suprapubic catheter
Item
Suprapubic catheter (SPC)
string
C0150798 (UMLS CUI 2011AA)
286861005 (SNOMED CT 2011_0131)
External genitalia
Item
External genitalia
string
C0227605 (UMLS CUI 2011AA)
77142006 (SNOMED CT 2011_0131)
Urethra
Item
Urethra
string
C0041967 (UMLS CUI 2011AA)
264255005 (SNOMED CT 2011_0131)
MTHU001321 (LOINC Version 232)
Vagina
Item
Vagina
string
C0042232 (UMLS CUI 2011AA)
76784001 (SNOMED CT 2011_0131)
MTHU014732 (LOINC Version 232)
Bladder
Item
Urinary Bladder
string
C0005682 (UMLS CUI 2011AA)
89837001 (SNOMED CT 2011_0131)
MTHU002918 (LOINC Version 232)
Cervix
Item
Cervix uteri
string
C0007874 (UMLS CUI 2011AA)
71252005 (SNOMED CT 2011_0131)
MTHU001800 (LOINC Version 232)
Uterus
Item
Uterus
string
C0042149 (UMLS CUI 2011AA)
35039007 (SNOMED CT 2011_0131)
MTHU002943 (LOINC Version 232)
adnexa
Item
Uterine adnexa
string
C0001575 (UMLS CUI 2011AA)
23043003 (SNOMED CT 2011_0131)
MTHU015033 (LOINC Version 232)
rectal: sphincter tone
Item
rectal: sphincter tone
string
hemorrhoids
Item
Haemorrhoids, Piles
string
C0019112 (UMLS CUI 2011AA)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
mass
Item
mass
string
Item Group
Physical Exam -MUSCULOSKELETAL
MUSCULOSKELETAL
Item
Musculoskeletal System, Musculo-skeletal system
string
C0026860 (UMLS CUI 2011AA)
26107004 (SNOMED CT 2011_0131)
MTHU001411 (LOINC Version 232)
Gait
Item
Gait, Manner of walking
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
Station
Item
Station
string
Digits
Item
Digits
string
C0582802 (UMLS CUI 2011AA)
82680008 (SNOMED CT 2011_0131)
MTHU015035 (LOINC Version 232)
Nails
Item
Nails
string
C0027342 (UMLS CUI 2011AA)
72651009 (SNOMED CT 2011_0131)
MTHU002041 (LOINC Version 232)
Joints, Bones, Muscles
Item
Joints, Bones, Muscles
text
39352004, 272673000, 71616004 (SNOMED CT 2011_0131)
C0022417 (UMLS CUI-1)
C0262950 (UMLS CUI-2)
C0026845 (UMLS CUI-3)
Head and Neck
Item
Head & Neck (inspection & palpation, ROM, stability, muscle strength, tone)
text
69536005, 45048000 (SNOMED CT 2011_0131)
C0018670 (UMLS CUI-1)
C0027530 (UMLS CUI-2)
Spine/Ribs/Pelvis
Item
Spine/Ribs/Pelvis (inspection & palpation, ROM, stability, muscle strength, tone)
string
Right Shoulder
Item
Right Shoulder (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0037004 (UMLS CUI 2011AA)
16982005 (SNOMED CT 2011_0131)
MTHU002689 (LOINC Version 232)
Right Elbow
Item
Right Elbow (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0013769 (UMLS CUI 2011AA)
127949000 (SNOMED CT 2011_0131)
MTHU002674 (LOINC Version 232)
Right Wrist
Item
Right Wrist (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0043262 (UMLS CUI 2011AA)
8205005 (SNOMED CT 2011_0131)
MTHU002691 (LOINC Version 232)
Left Shoulder
Item
Left Shoulder (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0037004 (UMLS CUI 2011AA)
16982005 (SNOMED CT 2011_0131)
MTHU002689 (LOINC Version 232)
Left Elbow
Item
Left Elbow (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0013769 (UMLS CUI 2011AA)
127949000 (SNOMED CT 2011_0131)
MTHU002674 (LOINC Version 232)
Left Wrist
Item
Left Wrist (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0043262 (UMLS CUI 2011AA)
8205005 (SNOMED CT 2011_0131)
MTHU002691 (LOINC Version 232)
Right Hip
Item
Right Hip (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0019552 (UMLS CUI 2011AA)
24136001 (SNOMED CT 2011_0131)
MTHU002686 (LOINC Version 232)
Right Knee
Item
Right Knee (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0022742 (UMLS CUI 2011AA)
304679005 (SNOMED CT 2011_0131)
MTHU002687 (LOINC Version 232)
Right Ankle
Item
Right Ankle (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
Left Hip
Item
Left Hip (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0019552 (UMLS CUI 2011AA)
24136001 (SNOMED CT 2011_0131)
MTHU002686 (LOINC Version 232)
Left Knee
Item
Left Knee (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0022742 (UMLS CUI 2011AA)
304679005 (SNOMED CT 2011_0131)
MTHU002687 (LOINC Version 232)
Left Ankle
Item
Left Ankle (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
Item Group
Physical Exam - EXTREMITIES
Significant for:
Item
Significant for:
string
pitting edema
Item
Pitting edema
string
C0333243 (UMLS CUI 2011AA)
139248000 (SNOMED CT 2011_0131)
pretibial: R / L
Item
pretibial: R / L
string
ankle: R / L
Item
ankle: R / L
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
foot: R / L
Item
foot: R / L
string
C0016504 (UMLS CUI 2011AA)
56459004 (SNOMED CT 2011_0131)
MTHU002679 (LOINC Version 232)
Pulses R/L: posterior tibial
Item
Posterior tibial pulse R/L
string
C1720310 (UMLS CUI 2011AA)
421568004 (SNOMED CT 2011_0131)
Pulses R/L: dorsalis pedis
Item
Pulses R/L: dorsalis pedis
string
C1706488 (UMLS CUI 2011AA)
421811005 (SNOMED CT 2011_0131)
capillary fill time R/L
Item
capillary fill time R/L
string
sensation by monofilament test R/L
Item
sensation by monofilament test R/L
string
toenails
Item
toenails
string
skin
Item
skin
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
Item Group
Physical Exam - LYMPHATIC
no adenopathy
Item
no adenopathy
boolean
adenopathy
Item
adenopathy (generalized, localized)
string
C1706304 (UMLS CUI 2011AA)
neck
Item
Neck, Collum, Cervical
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Axilla
Item
Axilla, axillary region
string
C0004454 (UMLS CUI 2011AA)
91470000 (SNOMED CT 2011_0131)
MTHU002668 (LOINC Version 232)
groin
Item
Inguinal region
string
C0018246 (UMLS CUI 2011AA)
26893007 (SNOMED CT 2011_0131)
MTHU002684 (LOINC Version 232)
other
Item
other
string
Item Group
Physical Exam - SKIN
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Item
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
boolean
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
inspection
Item
inspection, visual examination
string
C0199219 (UMLS CUI 2011AA)
32750006 (SNOMED CT 2011_0131)
Palpation
Item
Palpation
string
C0030247 (UMLS CUI 2011AA)
113011001 (SNOMED CT 2011_0131)
Item Group
Physical Exam - Wound and Incision Care
WOUND #
Item
Wound
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
WOUND LOCATION
Item
WOUND LOCATION
string
WOUND MEASUREMENT (Length, Width, Depth [cm])
Item
WOUND MEASUREMENT (Length, Width, Depth [cm])
string
UNDERMINING Wound
Item
UNDERMINING Wound
boolean
TUNNELING Wound
Item
TUNNELING Wound
boolean
SURROUNDING SKIN: WOUND BASE
Item
SURROUNDING SKIN: WOUND BASE
string
SENSATION
Item
Sensation, Esthesia, Sensory function, Sensory perception
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
EXUDATE
Item
EXUDATE
string
C0015388 (UMLS CUI 2011AA)
247450001 (SNOMED CT 2011_0131)
MTHU025016 (LOINC Version 232)
COLOR OF DRAINAGE
Item
COLOR OF DRAINAGE
string
ODOR: Before Cleaning
Item
ODOR: Before Cleaning
boolean
ODOR: After Cleaning
Item
ODOR: After Cleaning
boolean
CLEANSED WITH/IRRIGATED WITH
Item
CLEANSED WITH/IRRIGATED WITH
string
WOUND MED applied
Item
WOUND MED applied
string
FILLED WITH
Item
FILLED WITH
string
COVERED WITH
Item
COVERED WITH
string
SECURED WITH
Item
SECURED WITH
string
PRESSURE RELIEF
Item
PRESSURE RELIEF
string
COMMENTS
Item
COMMENTS
string
PHOTOGRAPH DATE
Item
PHOTOGRAPH DATE
date
NARRATIVE
Item
NARRATIVE
string
C1135957 (UMLS CUI 2011AA)
INCISION #
Item
Surgical incision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
LOCATION
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
CLOSURE TYPE
Item
CLOSURE TYPE
string
DRESSING TYPE
Item
DRESSING TYPE
string
DRESSING APPEARANCE
Item
DRESSING APPEARANCE
string
DRAINS
Item
Drains, Drain device
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
NARRATIVE
Item
NARRATIVE
string
C1135957 (UMLS CUI 2011AA)
Item Group
Physical Exam - NEUROLOGIC
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Item
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
boolean
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
Conciousness
Item
Consciousness related finding
string
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
Responsive to
Item
Responsive to
string
Orientation
Item
Orientation as to time, place and people
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
Proverb
Item
Proverb
string
Writing
Item
Writing
string
C2584304 (UMLS CUI 2011AA)
12261009 (SNOMED CT 2011_0131)
Reading
Item
Reading (activity)
string
C0034754 (UMLS CUI 2011AA)
50360004 (SNOMED CT 2011_0131)
Memory
Item
Memory function
string
C0025260 (UMLS CUI 2011AA)
303116000 (SNOMED CT 2011_0131)
MTHU021129 (LOINC Version 232)
Registration
Item
Registration
string
Naming Intact
Item
Naming Intact
string
Speech
Item
Speech, Speaking, using verbal communication
string
C0037817 (UMLS CUI 2011AA)
87335007 (SNOMED CT 2011_0131)
MTHU021528 (LOINC Version 232)
OTHER
Item
OTHER
string
Score normal
Item
Score normal
boolean
Concentration normal
Item
Concentration normal
boolean
Cranial nerves normal
Item
Cranial nerves normal
boolean
Comment
Item
Comment
string
Motor tone
Item
Muscle Tonus, Muscle tone, Muscle tension
string
C0026841 (UMLS CUI 2011AA)
10070541 (MedDRA 14.1)
MTHU015024 (LOINC Version 232)
Motor strength R/L
Item
Muscle Strength R/L
string
C0517349 (UMLS CUI 2011AA)
Grip R/L
Item
Grip R/L
string
C0220843 (UMLS CUI 2011AA)
Biceps R/L
Item
Biceps brachii, Biceps brachii muscle
string
C0559499 (UMLS CUI 2011AA)
16225001 (SNOMED CT 2011_0131)
MTHU014778 (LOINC Version 232)
Triceps R/L
Item
Triceps brachii muscle, Triceps brachii
string
C0559502 (UMLS CUI 2011AA)
40284004 (SNOMED CT 2011_0131)
MTHU014783 (LOINC Version 232)
Quadriceps R/L
Item
Quadriceps femoris muscle, Quadriceps femoris
string
C0224440 (UMLS CUI 2011AA)
21989003 (SNOMED CT 2011_0131)
Hip Extensors R/L
Item
Hip Extensors R/L
string
Dorsiflexion R/L
Item
Dorsiflexion R/L
string
Plantarflexion R/L
Item
Plantarflexion R/L
string
Sensation
Item
Sensation, Esthesia, Sensory function, Sensory perception
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
Pin prick
Item
Pin prick sensation, Discrimination between sharp and blunt
string
C0423557 (UMLS CUI 2011AA)
247315008 (SNOMED CT 2011_0131)
Comment
Item
Comment
string
Light touch
Item
Light touch
string
Vibration
Item
Vibration
string
C0459800 (UMLS CUI 2011AA)
33679000 (SNOMED CT 2011_0131)
MTHU021537 (LOINC Version 232)
Comment
Item
Comment
string
Position Sense
Item
Position Sense, Position sensation, Postural sense
string
C0234219 (UMLS CUI 2011AA)
73535003 (SNOMED CT 2011_0131)
Temperature
Item
Temperature
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Stereognosis
Item
Stereognosis, Stereognostic perception, Touch discrimination
string
C0038263 (UMLS CUI 2011AA)
22382001 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Biceps R/L
Item
Biceps reflex R/L
string
C0234151 (UMLS CUI 2011AA)
30901003 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Triceps R/L
Item
Triceps reflex R/L
string
C0422908 (UMLS CUI 2011AA)
271716008 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Brachioradialis R/L
Item
Deep Tendon Reflexes Brachioradialis R/L
string
Deep Tendon Reflexes Patellar R/L
Item
Patellar reflex, Knee reflex, Quadriceps reflex, Knee jerk (KJ) R/L
string
C0234147 (UMLS CUI 2011AA)
271714006 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Achilles R/L
Item
Deep Tendon Reflexes Achilles R/L
string
Abnormal reflexes
Item
Abnormal reflexes
string
C0034933 (UMLS CUI 2011AA)
46670006 (SNOMED CT 2011_0131)
10000171 (MedDRA 14.1)
R29.2 (ICD-10-CM Version 2010)
796.1 (ICD-9-CM Version 2011)
Involuntary Movements
Item
Involuntary Movements
string
C0427086 (UMLS CUI 2011AA)
267078001 (SNOMED CT 2011_0131)
10028042 (MedDRA 14.1)
E12728 (CTCAE 1105E)
Cerebellar Signs
Item
Cerebellar Signs
string
C0742038 (UMLS CUI 2011AA)
Gait
Item
Gait, Manner of walking
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
Comment
Item
Comment
string
Station
Item
Station
string
Item Group
PSYCHIATRIC
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Item
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
boolean
Judgement and Insight
Item
Judgement & Insight
text
61254005, 27026000 (SNOMED CT 2011_0131)
C0022423 (UMLS CUI-1)
C0233820 (UMLS CUI-2)
Orientation
Item
Orientation as to time, place and people
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
Recent Memory
Item
Recent Memory
string
C0233792 (UMLS CUI 2011AA)
69063000 (SNOMED CT 2011_0131)
Remote Memory
Item
Remote Memory, Palinmnesis
string
C0233793 (UMLS CUI 2011AA)
81964002 (SNOMED CT 2011_0131)
Mood/Affect
Item
Mood/Affect
text
85256008, 4065008 (SNOMED CT 2011_0131)
MTHU031584 (LOINC Version 232)
C0026516 (UMLS CUI-1)
C0001721 (UMLS CUI-2)
Item Group
Laboratory Results
Laboratory results reviewed
Item
Laboratory results reviewed
boolean
Prior 24 hour labs
Item
Prior 24 hour labs
string
C0587081 (UMLS CUI 2011AA)
118246004 (SNOMED CT 2011_0131)
Other
Item
Other
string
Item Group
Radiology Results
Radiology results reviewed
Item
Radiology results reviewed
boolean
radiology findings
Item
Radiology report
string
C1299496 (UMLS CUI 2011AA)
371527006 (SNOMED CT 2011_0131)
Item Group
ASSESSMENT
acceptable for surgery
Item
acceptable for surgery
boolean
progressing well
Item
progressing well
boolean
stable medically
Item
stable medically
boolean
C0205360 (UMLS CUI 2011AA)
58158008 (SNOMED CT 2011_0131)
MTHU015276 (LOINC Version 232)
Active Problems
Item
Active Problems
string
C0552582 (UMLS CUI 2011AA)
LP73189-0 (LOINC Version 232)
Other
Item
Other
string
Item Group
PLAN
Continue Home Regimen
Item
Continue Home Regimen
boolean
Continue Home Meds
Item
Continue Home Meds
boolean
Continue Chemotherapy
Item
Continue Chemotherapy
boolean
Continue IV Antibiotics
Item
Continue IV Antibiotics
boolean
Continue PO Antibiotics
Item
Continue PO Antibiotics
boolean
DVT Prophylaxis
Item
Deep venous thrombosis prophylaxis
boolean
C0853245 (UMLS CUI 2011AA)
10013880 (MedDRA 14.1)
O2 Protocol
Item
O2 Protocol
boolean
Follow Up X-Rays
Item
Follow Up X-Rays
boolean
UTI treatment
Item
UTI treatment
boolean
C0042029 (UMLS CUI 2011AA)
68566005 (SNOMED CT 2011_0131)
10046577 (MedDRA 14.1)
Monitor Blood Pressure and Heart Rate
Item
Monitor Blood Pressure and Heart Rate
boolean
Monitor Diabetes Mellitus
Item
Monitor Diabetes Mellitus
boolean
Accuchecks AC & HS
Item
Accuchecks AC & HS
boolean
Accuchecks Q6H
Item
Accuchecks Q6H
boolean
Sliding Scale Regular Insulin
Item
Sliding Scale Regular Insulin
boolean
C0021641 (UMLS CUI 2011AA)
67866001 (SNOMED CT 2011_0131)
MTHU019392 (LOINC Version 232)
Check Follow Up Labs
Item
Check Follow Up Labs
boolean
Appreciate following patient with you
Item
Appreciate following patient with you
boolean
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