ID

11249

Beschrijving

Form from HIS OpenVistA

Trefwoorden

  1. 23-02-12 23-02-12 -
  2. 07-08-14 07-08-14 - Martin Dugas
  3. 07-08-14 07-08-14 - Martin Dugas
  4. 26-06-15 26-06-15 - Martin Dugas
Geüploaded op

26 juni 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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H and P or consult specialty

  1. StudyEvent: HIS
    1. HIS
H and P or consult specialty
Beschrijving

H and P or consult specialty

Reason for visit
Beschrijving

Reason for visit

Datatype

string

Hauptbeschwerden
Beschrijving

CHIEF COMPLAINT

Datatype

string

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

HISTORY OF PRESENT ILLNESS

Anamnese der aktuellen Erkrankung
Beschrijving

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

Datatype

string

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

SOURCE(S) OF HISTORY

Datatype

integer

SOURCE(S) OF HISTORY comment
Beschrijving

SOURCE(S) OF HISTORY comment

Datatype

string

REVIEW OF SYSTEMS
Beschrijving

REVIEW OF SYSTEMS

REVIEW OF SYSTEMS: see form Review of systems
Beschrijving

REVIEW OF SYSTEMS: see form Review of systems

Datatype

string

PAST HISTORY
Beschrijving

PAST HISTORY

Erkrankung im Erwachsenenalter
Beschrijving

Adult Illness

Datatype

string

Alias
UMLS CUI 2011AA
C0277562
SNOMED CT 2011_0131
64342008
Kinderkrankheiten
Beschrijving

History of childhood diseases

Datatype

string

Alias
UMLS CUI 2011AA
C0489532
LOINC Version 232
MTHU001066
Frühere Operationen
Beschrijving

Surgeries

Datatype

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Trauma
Beschrijving

Injury

Datatype

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
Beschrijving

Female Specific History

Datum der letzten Menstruation
Beschrijving

Date of last menstrual period

Datatype

date

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

Date of last PAP

Datatype

date

Abstrich nach Papanicolaou
Beschrijving

last PAP Results

Datatype

string

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

Date of last MMG

Datatype

date

Mammographie
Beschrijving

last MMG Results

Datatype

string

Alias
UMLS CUI 2011AA
C0024671
SNOMED CT 2011_0131
71651007
MedDRA 14.1
10026735
Alter bei Menarche
Beschrijving

Age at menarche

Datatype

integer

Alias
UMLS CUI 2011AA
C1314691
SNOMED CT 2011_0131
398700009
LOINC Version 232
MTHU018825
Menstruation
Beschrijving

Describe Menses

Datatype

string

Alias
UMLS CUI 2011AA
C0025344
SNOMED CT 2011_0131
248957007
Kontrazeption
Beschrijving

Birth Control

Datatype

string

Alias
UMLS CUI 2011AA
C0700589
SNOMED CT 2011_0131
146680009
MedDRA 14.1
10010808
Schwangerschaft
Beschrijving

Pregnancies

Datatype

string

Alias
UMLS CUI 2011AA
C0032961
SNOMED CT 2011_0131
289908002
MedDRA 14.1
10036556
LOINC Version 232
MTHU035048
Abort
Beschrijving

Abortions

Datatype

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
Beschrijving

Number of full term pregnancies

Datatype

integer

Number of spontaneous abortions
Beschrijving

Number of spontaneous abortions

Datatype

integer

Number of therapeutic abortions
Beschrijving

Number of therapeutic abortions

Datatype

integer

Number of other types Abortions
Beschrijving

Number of other types Abortions

Datatype

integer

Age at first pregnancy
Beschrijving

Age at first pregnancy

Datatype

integer

FAMILY HISTORY
Beschrijving

FAMILY HISTORY

Familienanamnese
Beschrijving

Family history: see form Family Hx

Datatype

string

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

SOCIAL HISTORY

Sozialanamnese
Beschrijving

Social history: see form Social History

Datatype

string

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

ALLERGIES

No Known Allergies
Beschrijving

No Known Allergies

Datatype

boolean

Allergien
Beschrijving

Allergies text

Datatype

string

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

MEDICATIONS

Inpatient Medications
Beschrijving

Inpatient medications

Datatype

string

Alias
UMLS CUI 2011AA
C0013227
aktuelle Medikation
Beschrijving

Active medications

Datatype

string

Alias
UMLS CUI 2011AA
C1553892
Home Medications
Beschrijving

Home medications

Datatype

string

Alias
UMLS CUI 2011AA
C0013227
PHYSICAL EXAM - General
Beschrijving

PHYSICAL EXAM - General

Vitalzeichen
Beschrijving

VITALS

Datatype

string

Alias
UMLS CUI 2011AA
C0518766
SNOMED CT 2011_0131
46680005
LOINC Version 232
MTHU024540
Temperatur
Beschrijving

Temperature

Datatype

float

Maateenheden
  • °C
Alias
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
UMLS CUI-1
C0039476
°C
Pulsfrequenz
Beschrijving

Pulse Rate

Datatype

integer

Maateenheden
  • beats/min
Alias
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
UMLS CUI-1
C0232117
beats/min
Atemfrequenz
Beschrijving

Respiration Rate

Datatype

integer

Maateenheden
  • /min
Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
/min
Blutdruck
Beschrijving

Blood Pressure

Datatype

integer

Maateenheden
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
Schmerz
Beschrijving

Pain

Datatype

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
Gewicht
Beschrijving

Weight

Datatype

float

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

GENERAL

Datatype

text

Alias
UMLS CUI-1
C1148438
PHYSICAL EXAM - HEAD
Beschrijving

PHYSICAL EXAM - HEAD

HEAD (Normocephalic, atraumatic)
Beschrijving

HEAD

Datatype

boolean

Kopf
Beschrijving

Head text (significant for:)

Datatype

string

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

PHYSICAL EXAM - EYES

Auge
Beschrijving

EYES

Datatype

boolean

Alias
UMLS CUI 2011AA
C0015392
SNOMED CT 2011_0131
81745001
LOINC Version 232
MTHU000064
Pupille
Beschrijving

Pupils

Datatype

string

Alias
UMLS CUI 2011AA
C0034121
SNOMED CT 2011_0131
392406005
LOINC Version 232
MTHU015063
Bindehaut
Beschrijving

Conjunctivae

Datatype

string

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

Sclerae

Datatype

string

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

EOM

Datatype

string

Alias
UMLS CUI 2011AA
C0028863
SNOMED CT 2011_0131
67833000
LOINC Version 232
MTHU015037
Fundoskopie
Beschrijving

Funduscopic

Datatype

string

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

Physical Exam - Ears, Nose, Throat

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

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

Datatype

boolean

EAR R ext canal
Beschrijving

EAR R ext canal

Datatype

string

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

EAR R tympanic membrane (TM)

Datatype

string

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

EAR L ext canal

Datatype

string

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

EAR L tympanic membrane (TM)

Datatype

string

Alias
UMLS CUI 2011AA
C0041445
SNOMED CT 2011_0131
42859004
LOINC Version 232
MTHU014731
Nasenseptum
Beschrijving

NOSE Septum

Datatype

string

Alias
UMLS CUI 2011AA
C0027432
SNOMED CT 2011_0131
68426009
LOINC Version 232
MTHU015054
Nasenschleimhaut
Beschrijving

Nose Mucosa

Datatype

string

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

Nose R Nares

Datatype

string

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

Nose L Nares

Datatype

string

Alias
UMLS CUI 2011AA
C0595944
SNOMED CT 2011_0131
1797002
LOINC Version 232
MTHU015056
Mundschleimhaut
Beschrijving

Throat: Mouth mucosa

Datatype

string

Alias
UMLS CUI 2011AA
C0026639
SNOMED CT 2011_0131
113277000
Pharynx
Beschrijving

Pharynx

Datatype

string

Alias
UMLS CUI 2011AA
C0031354
SNOMED CT 2011_0131
54066008
LOINC Version 232
MTHU015061
Tonsillen
Beschrijving

Tonsils

Datatype

string

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

Dentition

Datatype

string

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

Physical Exam - Neck

Hals
Beschrijving

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

Datatype

boolean

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Adenopathie
Beschrijving

Adenopathy

Datatype

string

Alias
UMLS CUI 2011AA
C1706304
ICD-10-CM Version 2010
R59
Strömungsgeräuch über den Karotiden
Beschrijving

Carotid bruit

Datatype

string

Alias
UMLS CUI 2011AA
C0007280
SNOMED CT 2011_0131
419642000
MedDRA 14.1
10048777
Stauung der Jugularvenen
Beschrijving

JVD

Datatype

string

Alias
UMLS CUI 2011AA
C1719935
SNOMED CT 2011_0131
422008005
Schilddrüse
Beschrijving

Thyroid gland

Datatype

string

Alias
UMLS CUI 2011AA
C0040132
SNOMED CT 2011_0131
69748006
LOINC Version 232
MTHU007792
Trachea
Beschrijving

Trachea

Datatype

string

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

Physical Exam - BREAST

symmetric without masses
Beschrijving

symmetric without masses

Datatype

boolean

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

inspection: Right breast

Datatype

string

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

inspection: Right nipple

Datatype

string

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

inspection: Left breast

Datatype

string

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

inspection: Left nipple

Datatype

string

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

palpation: Right breast

Datatype

string

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

palpation: Right nipple

Datatype

string

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

palpation: Left breast

Datatype

string

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

palpation: Left nipple

Datatype

string

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

Physical Exam - CHEST

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

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

Datatype

boolean

Chest significant for:
Beschrijving

Chest significant for:

Datatype

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Ort
Beschrijving

Location

Datatype

string

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

Additional lung sounds

Datatype

string

Alias
UMLS CUI 2011AA
C0035234
SNOMED CT 2011_0131
52653008
MedDRA 14.1
10064779
Ort
Beschrijving

Location

Datatype

string

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

Physical Exam - HEART

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

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

Datatype

boolean

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

Palpation: PMI is

Datatype

string

Rhythm
Beschrijving

Rhythm

Datatype

string

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

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

Datatype

string

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

PE HEART RUB TEXT

Datatype

string

PE HEART OTHER SOUNDS TEXT
Beschrijving

PE HEART OTHER SOUNDS TEXT

Datatype

string

Murmur: grade
Beschrijving

Murmur: grade

Datatype

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
Beschrijving

Murmur heard best at

Datatype

string

Murmur radiates
Beschrijving

Murmur radiates

Datatype

string

Heart - OTHER1
Beschrijving

Heart - OTHER1

Datatype

string

Physical Exam - VASCULAR
Beschrijving

Physical Exam - VASCULAR

Pulses present and equal bilat.
Beschrijving

Pulses present and equal bilat.

Datatype

boolean

Aorta
Beschrijving

Aorta

Datatype

string

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

Pulses R/L: carotid

Datatype

string

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

Pulses R/L: brachial

Datatype

string

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

Pulses R/L: radial

Datatype

string

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

Pulses R/L: femoral

Datatype

string

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

Pulses R/L: popliteal

Datatype

string

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

Pulses R/L: posterior tibial

Datatype

string

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

Pulses R/L: dorsalis pedis

Datatype

string

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

Physical Exam - ABDOMEN

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

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

Datatype

boolean

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

Appearance

Datatype

string

Darmgeräusche
Beschrijving

Bowel sounds

Datatype

string

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

Midepigastric bruit

Datatype

string

Bauchdeckenabwehrspannung
Beschrijving

Abdominal tenderness

Datatype

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
Beschrijving

Rebound

Datatype

string

Leber
Beschrijving

Liver

Datatype

string

Alias
UMLS CUI 2011AA
C0023884
SNOMED CT 2011_0131
10200004
LOINC Version 232
MTHU002039
Milz
Beschrijving

Spleen

Datatype

string

Alias
UMLS CUI 2011AA
C0037993
SNOMED CT 2011_0131
78961009
LOINC Version 232
MTHU012104
Hernie
Beschrijving

Hernia

Datatype

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
Beschrijving

Physical Exam - GENITOURINARY/RECTAL: MALE

GU Assessment
Beschrijving

GU Assessment

Datatype

string

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

Urine appears

Datatype

string

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

Urine is adequate

Datatype

string

Alias
UMLS CUI 2011AA
C0042036
SNOMED CT 2011_0131
78014005
LOINC Version 232
MTHU001343
Urinvolumen
Beschrijving

Urine Output [ml]

Datatype

integer

Alias
UMLS CUI 2011AA
C1287298
SNOMED CT 2011_0131
365678000
MedDRA 14.1
10059894
LOINC Version 232
MTHU024573
Blasenkatheter
Beschrijving

Foley catheter

Datatype

string

Alias
UMLS CUI 2011AA
C0179804
MedDRA 14.1
10016892
suprapubischer Katheter
Beschrijving

Suprapubic catheter

Datatype

string

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

scrotal contents

Datatype

string

Penis
Beschrijving

Penis

Datatype

string

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

rectal: sphincter tone

Datatype

string

Hämorrhoiden
Beschrijving

hemorrhoids

Datatype

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
Prostata
Beschrijving

Prostate

Datatype

string

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

mass

Datatype

string

Physical Exam - GENITOURINARY/RECTAL: FEMALE
Beschrijving

Physical Exam - GENITOURINARY/RECTAL: FEMALE

GU Assessment FEMALE
Beschrijving

GU Assessment FEMALE

Datatype

string

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

Urine appears

Datatype

string

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

Urine is adequate

Datatype

string

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

Urine Output [ml]

Datatype

integer

Alias
UMLS CUI 2011AA
C1287298
SNOMED CT 2011_0131
365678000
MedDRA 14.1
10059894
LOINC Version 232
MTHU024573
Blasenkatheter
Beschrijving

Foley catheter

Datatype

string

Alias
UMLS CUI 2011AA
C0179804
MedDRA 14.1
10016892
suprapubischer Katheter
Beschrijving

Suprapubic catheter

Datatype

string

Alias
UMLS CUI 2011AA
C0150798
SNOMED CT 2011_0131
286861005
Externes Genitale
Beschrijving

External genitalia

Datatype

string

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

Urethra

Datatype

string

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

Vagina

Datatype

string

Alias
UMLS CUI 2011AA
C0042232
SNOMED CT 2011_0131
76784001
LOINC Version 232
MTHU014732
Harnblase
Beschrijving

Bladder

Datatype

string

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

Cervix

Datatype

string

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

Uterus

Datatype

string

Alias
UMLS CUI 2011AA
C0042149
SNOMED CT 2011_0131
35039007
LOINC Version 232
MTHU002943
Adnexe
Beschrijving

adnexa

Datatype

string

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

rectal: sphincter tone

Datatype

string

Hämorrhoiden
Beschrijving

hemorrhoids

Datatype

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
Beschrijving

mass

Datatype

string

Physical Exam -MUSCULOSKELETAL
Beschrijving

Physical Exam -MUSCULOSKELETAL

Muskuloskeletales System
Beschrijving

MUSCULOSKELETAL

Datatype

string

Alias
UMLS CUI 2011AA
C0026860
SNOMED CT 2011_0131
26107004
LOINC Version 232
MTHU001411
Gang
Beschrijving

Gait

Datatype

string

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

Station

Datatype

string

Finger
Beschrijving

Digits

Datatype

string

Alias
UMLS CUI 2011AA
C0582802
SNOMED CT 2011_0131
82680008
LOINC Version 232
MTHU015035
Nägel
Beschrijving

Nails

Datatype

string

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

Joints, Bones, Muscles

Datatype

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)
Beschrijving

Head and Neck

Datatype

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)
Beschrijving

Spine/Ribs/Pelvis

Datatype

string

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

Right Shoulder

Datatype

string

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

Right Elbow

Datatype

string

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

Right Wrist

Datatype

string

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

Left Shoulder

Datatype

string

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

Left Elbow

Datatype

string

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

Left Wrist

Datatype

string

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

Right Hip

Datatype

string

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

Right Knee

Datatype

string

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

Right Ankle

Datatype

string

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

Left Hip

Datatype

string

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

Left Knee

Datatype

string

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

Left Ankle

Datatype

string

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

Physical Exam - EXTREMITIES

Significant for:
Beschrijving

Significant for:

Datatype

string

Pitting edema
Beschrijving

pitting edema

Datatype

string

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

pretibial: R / L

Datatype

string

ankle: R / L
Beschrijving

ankle: R / L

Datatype

string

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

foot: R / L

Datatype

string

Alias
UMLS CUI 2011AA
C0016504
SNOMED CT 2011_0131
56459004
LOINC Version 232
MTHU002679
Tibialis posterior-Puls R/L
Beschrijving

Pulses R/L: posterior tibial

Datatype

string

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

Pulses R/L: dorsalis pedis

Datatype

string

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

capillary fill time R/L

Datatype

string

sensation by monofilament test R/L
Beschrijving

sensation by monofilament test R/L

Datatype

string

toenails
Beschrijving

toenails

Datatype

string

Haut
Beschrijving

skin

Datatype

string

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

Physical Exam - LYMPHATIC

no adenopathy
Beschrijving

no adenopathy

Datatype

boolean

Adenopathie
Beschrijving

adenopathy

Datatype

string

Alias
UMLS CUI 2011AA
C1706304
Hals
Beschrijving

neck

Datatype

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Axilla
Beschrijving

Axilla

Datatype

string

Alias
UMLS CUI 2011AA
C0004454
SNOMED CT 2011_0131
91470000
LOINC Version 232
MTHU002668
Leistenregion
Beschrijving

groin

Datatype

string

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

other

Datatype

string

Physical Exam - SKIN
Beschrijving

Physical Exam - SKIN

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

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

Datatype

boolean

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Inspektion
Beschrijving

inspection

Datatype

string

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

Palpation

Datatype

string

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

Physical Exam - Wound and Incision Care

Wunde
Beschrijving

WOUND #

Datatype

string

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

WOUND LOCATION

Datatype

string

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

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

Datatype

string

UNDERMINING Wound
Beschrijving

UNDERMINING Wound

Datatype

boolean

TUNNELING Wound
Beschrijving

TUNNELING Wound

Datatype

boolean

SURROUNDING SKIN: WOUND BASE
Beschrijving

SURROUNDING SKIN: WOUND BASE

Datatype

string

Sensation, Esthesia, Sensory function, Sensory perception
Beschrijving

SENSATION

Datatype

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
Exsudat
Beschrijving

EXUDATE

Datatype

string

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

COLOR OF DRAINAGE

Datatype

string

ODOR: Before Cleaning
Beschrijving

ODOR: Before Cleaning

Datatype

boolean

ODOR: After Cleaning
Beschrijving

ODOR: After Cleaning

Datatype

boolean

CLEANSED WITH/IRRIGATED WITH
Beschrijving

CLEANSED WITH/IRRIGATED WITH

Datatype

string

WOUND MED applied
Beschrijving

WOUND MED applied

Datatype

string

FILLED WITH
Beschrijving

FILLED WITH

Datatype

string

COVERED WITH
Beschrijving

COVERED WITH

Datatype

string

SECURED WITH
Beschrijving

SECURED WITH

Datatype

string

PRESSURE RELIEF
Beschrijving

PRESSURE RELIEF

Datatype

string

COMMENTS
Beschrijving

COMMENTS

Datatype

string

PHOTOGRAPH DATE
Beschrijving

PHOTOGRAPH DATE

Datatype

date

NARRATIVE
Beschrijving

NARRATIVE

Datatype

string

Alias
UMLS CUI 2011AA
C1135957
Inzision
Beschrijving

INCISION #

Datatype

string

Alias
UMLS CUI 2011AA
C0184898
SNOMED CT 2011_0131
34896006
Lokalisation
Beschrijving

LOCATION

Datatype

string

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

CLOSURE TYPE

Datatype

string

DRESSING TYPE
Beschrijving

DRESSING TYPE

Datatype

string

DRESSING APPEARANCE
Beschrijving

DRESSING APPEARANCE

Datatype

string

Drainage
Beschrijving

DRAINS

Datatype

string

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

NARRATIVE

Datatype

string

Alias
UMLS CUI 2011AA
C1135957
Physical Exam - NEUROLOGIC
Beschrijving

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
Beschrijving

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

Datatype

boolean

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
Bewusstseinslage
Beschrijving

Conciousness

Datatype

string

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

Responsive to

Datatype

string

Orientierung
Beschrijving

Orientation

Datatype

string

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

Proverb

Datatype

string

Schreiben
Beschrijving

Writing

Datatype

string

Alias
UMLS CUI 2011AA
C2584304
SNOMED CT 2011_0131
12261009
Lesen
Beschrijving

Reading

Datatype

string

Alias
UMLS CUI 2011AA
C0034754
SNOMED CT 2011_0131
50360004
Gedächtnis
Beschrijving

Memory

Datatype

string

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

Registration

Datatype

string

Naming Intact
Beschrijving

Naming Intact

Datatype

string

Sprache
Beschrijving

Speech

Datatype

string

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

OTHER

Datatype

string

Score normal
Beschrijving

Score normal

Datatype

boolean

Concentration normal
Beschrijving

Concentration normal

Datatype

boolean

Cranial nerves normal
Beschrijving

Cranial nerves normal

Datatype

boolean

Comment
Beschrijving

Comment

Datatype

string

Muskeltonus
Beschrijving

Motor tone

Datatype

string

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

Motor strength R/L

Datatype

string

Alias
UMLS CUI 2011AA
C0517349
Grip R/L
Beschrijving

Grip R/L

Datatype

string

Alias
UMLS CUI 2011AA
C0220843
Biceps
Beschrijving

Biceps R/L

Datatype

string

Alias
UMLS CUI 2011AA
C0559499
SNOMED CT 2011_0131
16225001
LOINC Version 232
MTHU014778
Triceps
Beschrijving

Triceps R/L

Datatype

string

Alias
UMLS CUI 2011AA
C0559502
SNOMED CT 2011_0131
40284004
LOINC Version 232
MTHU014783
Quadriceps
Beschrijving

Quadriceps R/L

Datatype

string

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

Hip Extensors R/L

Datatype

string

Dorsiflexion R/L
Beschrijving

Dorsiflexion R/L

Datatype

string

Plantarflexion R/L
Beschrijving

Plantarflexion R/L

Datatype

string

Sensation, Esthesia, Sensory function, Sensory perception
Beschrijving

Sensation

Datatype

string

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

Pin prick

Datatype

string

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

Comment

Datatype

string

Light touch
Beschrijving

Light touch

Datatype

string

Vibration
Beschrijving

Vibration

Datatype

string

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

Comment

Datatype

string

Position Sense, Position sensation, Postural sense
Beschrijving

Position Sense

Datatype

string

Alias
UMLS CUI 2011AA
C0234219
SNOMED CT 2011_0131
73535003
Temperatur
Beschrijving

Temperature

Datatype

string

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

Stereognosis

Datatype

string

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

Deep Tendon Reflexes Biceps R/L

Datatype

string

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

Deep Tendon Reflexes Triceps R/L

Datatype

string

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

Deep Tendon Reflexes Brachioradialis R/L

Datatype

string

Patellar-Reflex
Beschrijving

Deep Tendon Reflexes Patellar R/L

Datatype

string

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

Deep Tendon Reflexes Achilles R/L

Datatype

string

Abnorme Reflexe
Beschrijving

Abnormal reflexes

Datatype

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
Beschrijving

Involuntary Movements

Datatype

string

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

Cerebellar Signs

Datatype

string

Alias
UMLS CUI 2011AA
C0742038
Gang
Beschrijving

Gait

Datatype

string

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

Comment

Datatype

string

Station
Beschrijving

Station

Datatype

string

PSYCHIATRIC
Beschrijving

PSYCHIATRIC

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

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

Datatype

boolean

Judgement & Insight
Beschrijving

Judgement and Insight

Datatype

text

Alias
SNOMED CT 2011_0131
61254005, 27026000
UMLS CUI-1
C0022423
UMLS CUI-2
C0233820
Orientierung
Beschrijving

Orientation

Datatype

string

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

Recent Memory

Datatype

string

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

Remote Memory

Datatype

string

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

Mood/Affect

Datatype

text

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

Laboratory Results

Laboratory results reviewed
Beschrijving

Laboratory results reviewed

Datatype

boolean

Prior 24 hour labs
Beschrijving

Prior 24 hour labs

Datatype

string

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

Other

Datatype

string

Radiology Results
Beschrijving

Radiology Results

Radiology results reviewed
Beschrijving

Radiology results reviewed

Datatype

boolean

Radiologie-Befund
Beschrijving

radiology findings

Datatype

string

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

ASSESSMENT

acceptable for surgery
Beschrijving

acceptable for surgery

Datatype

boolean

progressing well
Beschrijving

progressing well

Datatype

boolean

stable medically
Beschrijving

stable medically

Datatype

boolean

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

Active Problems

Datatype

string

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

Other

Datatype

string

PLAN
Beschrijving

PLAN

Continue Home Regimen
Beschrijving

Continue Home Regimen

Datatype

boolean

Continue Home Meds
Beschrijving

Continue Home Meds

Datatype

boolean

Continue Chemotherapy
Beschrijving

Continue Chemotherapy

Datatype

boolean

Continue IV Antibiotics
Beschrijving

Continue IV Antibiotics

Datatype

boolean

Continue PO Antibiotics
Beschrijving

Continue PO Antibiotics

Datatype

boolean

Deep venous thrombosis prophylaxis
Beschrijving

DVT Prophylaxis

Datatype

boolean

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

O2 Protocol

Datatype

boolean

Follow Up X-Rays
Beschrijving

Follow Up X-Rays

Datatype

boolean

UTI treatment
Beschrijving

UTI treatment

Datatype

boolean

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

Monitor Blood Pressure and Heart Rate

Datatype

boolean

Monitor Diabetes Mellitus
Beschrijving

Monitor Diabetes Mellitus

Datatype

boolean

Accuchecks AC & HS
Beschrijving

Accuchecks AC & HS

Datatype

boolean

Accuchecks Q6H
Beschrijving

Accuchecks Q6H

Datatype

boolean

Sliding Scale Regular Insulin
Beschrijving

Sliding Scale Regular Insulin

Datatype

boolean

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

Check Follow Up Labs

Datatype

boolean

Appreciate following patient with you
Beschrijving

Appreciate following patient with you

Datatype

boolean

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Reason for visit
Item
Reason for visit
string
CHIEF COMPLAINT
Item
Hauptbeschwerden
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Item
Anamnese der aktuellen Erkrankung
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
REVIEW OF SYSTEMS: see form Review of systems
Item
REVIEW OF SYSTEMS: see form Review of systems
string
Item Group
Adult Illness
Item
Erkrankung im Erwachsenenalter
string
C0277562 (UMLS CUI 2011AA)
64342008 (SNOMED CT 2011_0131)
History of childhood diseases
Item
Kinderkrankheiten
string
C0489532 (UMLS CUI 2011AA)
MTHU001066 (LOINC Version 232)
Surgeries
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Injury
Item
Trauma
string
C0175677 (UMLS CUI 2011AA)
417746004 (SNOMED CT 2011_0131)
10022116 (MedDRA 14.1)
T14.9 (ICD-10-CM Version 2010)
Date of last menstrual period
Item
Datum der letzten Menstruation
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
Abstrich nach Papanicolaou
string
C0079104 (UMLS CUI 2011AA)
10041205 (MedDRA 14.1)
Date of last MMG
Item
Date of last mammogram (MMG)
date
last MMG Results
Item
Mammographie
string
C0024671 (UMLS CUI 2011AA)
71651007 (SNOMED CT 2011_0131)
10026735 (MedDRA 14.1)
Age at menarche
Item
Alter bei Menarche
integer
C1314691 (UMLS CUI 2011AA)
398700009 (SNOMED CT 2011_0131)
MTHU018825 (LOINC Version 232)
Describe Menses
Item
Menstruation
string
C0025344 (UMLS CUI 2011AA)
248957007 (SNOMED CT 2011_0131)
Birth Control
Item
Kontrazeption
string
C0700589 (UMLS CUI 2011AA)
146680009 (SNOMED CT 2011_0131)
10010808 (MedDRA 14.1)
Pregnancies
Item
Schwangerschaft
string
C0032961 (UMLS CUI 2011AA)
289908002 (SNOMED CT 2011_0131)
10036556 (MedDRA 14.1)
MTHU035048 (LOINC Version 232)
Abortions
Item
Abort
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: see form Family Hx
Item
Familienanamnese
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
Item Group
Social history: see form Social History
Item
Sozialanamnese
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
Item Group
No Known Allergies
Item
No Known Allergies
boolean
Allergies text
Item
Allergien
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
Item Group
Inpatient medications
Item
Inpatient Medications
string
C0013227 (UMLS CUI 2011AA)
Active medications
Item
aktuelle Medikation
string
C1553892 (UMLS CUI 2011AA)
Home medications
Item
Home Medications
string
C0013227 (UMLS CUI 2011AA)
VITALS
Item
Vitalzeichen
string
C0518766 (UMLS CUI 2011AA)
46680005 (SNOMED CT 2011_0131)
MTHU024540 (LOINC Version 232)
Temperature
Item
Temperatur
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulsfrequenz
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Atemfrequenz
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blutdruck
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
Pain
Item
Schmerz
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
Gewicht
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)
HEAD
Item
HEAD (Normocephalic, atraumatic)
boolean
Head text (significant for:)
Item
Kopf
string
C0018670 (UMLS CUI 2011AA)
69536005 (SNOMED CT 2011_0131)
MTHU001435 (LOINC Version 232)
EYES
Item
Auge
boolean
C0015392 (UMLS CUI 2011AA)
81745001 (SNOMED CT 2011_0131)
MTHU000064 (LOINC Version 232)
Pupils
Item
Pupille
string
C0034121 (UMLS CUI 2011AA)
392406005 (SNOMED CT 2011_0131)
MTHU015063 (LOINC Version 232)
Conjunctivae
Item
Bindehaut
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
Fundoskopie
string
C0029090 (UMLS CUI 2011AA)
274798009 (SNOMED CT 2011_0131)
10017519 (MedDRA 14.1)
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
Nasenseptum
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Nose Mucosa
Item
Nasenschleimhaut
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
Mundschleimhaut
string
C0026639 (UMLS CUI 2011AA)
113277000 (SNOMED CT 2011_0131)
Pharynx
Item
Pharynx
string
C0031354 (UMLS CUI 2011AA)
54066008 (SNOMED CT 2011_0131)
MTHU015061 (LOINC Version 232)
Tonsils
Item
Tonsillen
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)
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Item
Hals
boolean
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Adenopathy
Item
Adenopathie
string
C1706304 (UMLS CUI 2011AA)
R59 (ICD-10-CM Version 2010)
Carotid bruit
Item
Strömungsgeräuch über den Karotiden
string
C0007280 (UMLS CUI 2011AA)
419642000 (SNOMED CT 2011_0131)
10048777 (MedDRA 14.1)
JVD
Item
Stauung der Jugularvenen
string
C1719935 (UMLS CUI 2011AA)
422008005 (SNOMED CT 2011_0131)
Thyroid gland
Item
Schilddrüse
string
C0040132 (UMLS CUI 2011AA)
69748006 (SNOMED CT 2011_0131)
MTHU007792 (LOINC Version 232)
Trachea
Item
Trachea
string
C0040578 (UMLS CUI 2011AA)
44567001 (SNOMED CT 2011_0131)
MTHU009117 (LOINC Version 232)
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)
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
Ort
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
Ort
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
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
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)
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
Darmgeräusche
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
Midepigastric bruit
Item
Midepigastric bruit
string
Abdominal tenderness
Item
Bauchdeckenabwehrspannung
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
Leber
string
C0023884 (UMLS CUI 2011AA)
10200004 (SNOMED CT 2011_0131)
MTHU002039 (LOINC Version 232)
Spleen
Item
Milz
string
C0037993 (UMLS CUI 2011AA)
78961009 (SNOMED CT 2011_0131)
MTHU012104 (LOINC Version 232)
Hernia
Item
Hernie
string
C0019270 (UMLS CUI 2011AA)
414403008 (SNOMED CT 2011_0131)
10019909 (MedDRA 14.1)
K40-K46 (ICD-10-CM Version 2010)
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
Urinvolumen
integer
C1287298 (UMLS CUI 2011AA)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
Foley catheter
Item
Blasenkatheter
string
C0179804 (UMLS CUI 2011AA)
10016892 (MedDRA 14.1)
Suprapubic catheter
Item
suprapubischer Katheter
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
Hämorrhoiden
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
Prostata
string
C0033572 (UMLS CUI 2011AA)
41216001 (SNOMED CT 2011_0131)
MTHU004957 (LOINC Version 232)
mass
Item
mass
string
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
Blasenkatheter
string
C0179804 (UMLS CUI 2011AA)
10016892 (MedDRA 14.1)
Suprapubic catheter
Item
suprapubischer Katheter
string
C0150798 (UMLS CUI 2011AA)
286861005 (SNOMED CT 2011_0131)
External genitalia
Item
Externes Genitale
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
Harnblase
string
C0005682 (UMLS CUI 2011AA)
89837001 (SNOMED CT 2011_0131)
MTHU002918 (LOINC Version 232)
Cervix
Item
Cervix
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
Adnexe
string
C0001575 (UMLS CUI 2011AA)
23043003 (SNOMED CT 2011_0131)
MTHU015033 (LOINC Version 232)
rectal: sphincter tone
Item
rectal: sphincter tone
string
hemorrhoids
Item
Hämorrhoiden
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
MUSCULOSKELETAL
Item
Muskuloskeletales System
string
C0026860 (UMLS CUI 2011AA)
26107004 (SNOMED CT 2011_0131)
MTHU001411 (LOINC Version 232)
Gait
Item
Gang
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
Station
Item
Station
string
Digits
Item
Finger
string
C0582802 (UMLS CUI 2011AA)
82680008 (SNOMED CT 2011_0131)
MTHU015035 (LOINC Version 232)
Nails
Item
Nägel
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)
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
Tibialis posterior-Puls 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
Haut
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
no adenopathy
Item
no adenopathy
boolean
adenopathy
Item
Adenopathie
string
C1706304 (UMLS CUI 2011AA)
neck
Item
Hals
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Axilla
Item
Axilla
string
C0004454 (UMLS CUI 2011AA)
91470000 (SNOMED CT 2011_0131)
MTHU002668 (LOINC Version 232)
groin
Item
Leistenregion
string
C0018246 (UMLS CUI 2011AA)
26893007 (SNOMED CT 2011_0131)
MTHU002684 (LOINC Version 232)
other
Item
other
string
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
Inspektion
string
C0199219 (UMLS CUI 2011AA)
32750006 (SNOMED CT 2011_0131)
Palpation
Item
Palpation
string
C0030247 (UMLS CUI 2011AA)
113011001 (SNOMED CT 2011_0131)
WOUND #
Item
Wunde
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
Exsudat
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
Inzision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
LOCATION
Item
Lokalisation
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
Drainage
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
NARRATIVE
Item
NARRATIVE
string
C1135957 (UMLS CUI 2011AA)
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
Bewusstseinslage
string
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
Responsive to
Item
Responsive to
string
Orientation
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
Proverb
Item
Proverb
string
Writing
Item
Schreiben
string
C2584304 (UMLS CUI 2011AA)
12261009 (SNOMED CT 2011_0131)
Reading
Item
Lesen
string
C0034754 (UMLS CUI 2011AA)
50360004 (SNOMED CT 2011_0131)
Memory
Item
Gedächtnis
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
Sprache
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
Muskeltonus
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
string
C0559499 (UMLS CUI 2011AA)
16225001 (SNOMED CT 2011_0131)
MTHU014778 (LOINC Version 232)
Triceps R/L
Item
Triceps
string
C0559502 (UMLS CUI 2011AA)
40284004 (SNOMED CT 2011_0131)
MTHU014783 (LOINC Version 232)
Quadriceps R/L
Item
Quadriceps
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
Temperatur
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
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
Abnorme Reflexe
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
Gang
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
Comment
Item
Comment
string
Station
Item
Station
string
Item Group
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
Orientierung
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)
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
Radiology results reviewed
Item
Radiology results reviewed
boolean
radiology findings
Item
Radiologie-Befund
string
C1299496 (UMLS CUI 2011AA)
371527006 (SNOMED CT 2011_0131)
Item Group
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
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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