ID

11250

Description

Form from HIS OpenVistA

Keywords

Versions (2)
  1. 2/26/12 2/26/12 -
  2. 6/26/15 6/26/15 - Martin Dugas
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June 26, 2015

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TRANSFER ASSESSMENT INTERDISCIPLINARY NOTE

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
Transfer assessment
Description

Transfer assessment

ADMITTING DIAGNOSIS (AD)
Description

ADMITTING DIAGNOSIS

Data type

string

Alias
UMLS CUI 2011AA
C0332133
SNOMED CT 2011_0131
52870002
Treating Physician, Treating Doctor
Description

DOCTOR

Data type

string

Alias
UMLS CUI 2011AA
C1710470
Date of admission
Description

Admission Date

Data type

date

Alias
UMLS CUI 2011AA
C1302393
SNOMED CT 2011_0131
399423000
LOINC Version 232
MTHU029790
FAMILY NOTIFIED
Description

FAMILY NOTIFIED

Data type

boolean

BELONGINGS WITH PATIENT
Description

BELONGINGS WITH PATIENT

Data type

boolean

MEDICATIONS WITH PATIENT
Description

MEDICATIONS WITH PATIENT

Data type

boolean

IV MEDICATIONS WITH PATIENT
Description

IV MEDICATIONS WITH PATIENT

Data type

boolean

PENDING LABS
Description

PENDING LABS

Data type

string

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
Respiratory Rate (/min)
Description

Respiratory Rate (/min)

Data type

integer

Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
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
Date surgery
Description

Date surgery

Data type

date

Alias
LOINC Version 232
MTHU019327
UMLS CUI-1
C1628561
CODE STATUS
Description

CODE STATUS

Data type

string

DATE CODE STATUS ORDERED
Description

DATE CODE STATUS ORDERED

Data type

date

REASON FOR TRANSFER
Description

REASON FOR TRANSFER

Data type

string

Alias
UMLS CUI 2011AA
C1547731
LOINC Version 232
MTHU019076
Mode of transfer
Description

MODE OF TRANSFER

Data type

string

Alias
UMLS CUI 2011AA
C1718076
LOINC Version 232
MTHU021155
Functional Status, Level of function
Description

LEVEL OF FUNCTION

Data type

string

Alias
UMLS CUI 2011AA
C0598463
LOINC Version 232
MTHU027728
Mental Status, Mental State
Description

Mental Status

Data type

string

Alias
UMLS CUI 2011AA
C0278060
SNOMED CT 2011_0131
36456004
LOINC Version 232
MTHU001424
CTCAE 1105E
MTHU117157
Patient activity
Description

Level of Activity

Data type

string

Alias
UMLS CUI 2011AA
C0451369
SNOMED CT 2011_0131
273688003
Activities of Daily Living (ADL), Activities of everyday life
Description

Activities of Daily Living

Data type

string

Alias
UMLS CUI 2011AA
C0001288
SNOMED CT 2011_0131
129025006
Diet
Description

DIET

Data type

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Tube Feeding via @ with @ strength of @
Description

Tube Feeding via @ with @ strength of @

Data type

string

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Last residual amount was @ CC'S and it was checked at @
Description

Last residual amount was @ CC'S and it was checked at @

Data type

string

IV Therapy
Description

IV Therapy

Alias
UMLS CUI-1
C1411942
intravenous therapy
Description

IV THERAPY

Data type

string

Alias
UMLS CUI 2011AA
C1411942
Size of catheter
Description

Catheter Size

Data type

string

Alias
UMLS CUI 2011AA
C0449963
SNOMED CT 2011_0131
260967009
Location
Description

LOCATION

Data type

string

Alias
UMLS CUI 2011AA
C0450429
SNOMED CT 2011_0131
246267002
Intravenous fluid, Fluid for intravenous administration
Description

IV Fluid

Data type

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
LEFT TO COUNT [ml]
Description

LEFT TO COUNT [ml]

Data type

integer

Rate: @ ml/hr
Description

Rate: @ ml/hr

Data type

integer

IV Site APPEARANCE
Description

IV Site APPEARANCE

Data type

string

Central venous catheter (CVC), Central venous line
Description

CENTRAL LINE PORT

Data type

string

Alias
UMLS CUI 2011AA
C1145640
SNOMED CT 2011_0131
52124006
Intravenous fluid, Fluid for intravenous administration
Description

IV Fluid

Data type

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Description

TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr

Data type

string

Alias
UMLS CUI 2011AA
C0030548, C0023779
SNOMED CT 2011_0131
225372007, 70106000
MedDRA 14.1
10044107
LOINC Version 232
MTHU014331, MTHU003688
ICD-9-CM Version 2011
99.15
IV Site APPEARANCE
Description

IV Site APPEARANCE

Data type

string

SITE CHANGE DUE
Description

SITE CHANGE DUE

Data type

date

IV REASSESSMENT
Description

IV REASSESSMENT

Data type

string

IV Site APPEARANCE
Description

IV Site APPEARANCE

Data type

string

NARRATIVE
Description

NARRATIVE

Data type

string

Wound
Description

Wound

Alias
UMLS CUI-1
C0043250
WOUND CARE
Description

WOUND CARE

Data type

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
SITE: LAST DRESSING CHANGE
Description

SITE: LAST DRESSING CHANGE

Data type

string

ELIMINATION
Description

ELIMINATION

Alias
UMLS CUI-1
C0221102
Date of last bowel movement
Description

Date of last bowel movement

Data type

date

Alias
UMLS CUI 2011AA
C0011135
SNOMED CT 2011_0131
39211005
Is the patient incontinent of stool?
Description

Is the patient incontinent of stool?

Data type

string

Alias
UMLS CUI 2011AA
C0015732
SNOMED CT 2011_0131
72042002
MedDRA 14.1
10016092
LOINC Version 232
MTHU013375
ICD-10-CM Version 2010
R15
ICD-9-CM Version 2011
787.6
CTCAE 1105E
E10693
Is the patient incontinent of urine?
Description

Is the patient incontinent of urine?

Data type

string

Alias
UMLS CUI 2011AA
C0042024
SNOMED CT 2011_0131
165232002
MedDRA 14.1
10046543
ICD-10-CM Version 2010
R32
ICD-9-CM Version 2011
788.3
CTCAE 1105E
E13042
OTHER CARE
Description

OTHER CARE

O2, Oxygen
Description

OXYGEN

Data type

string

Alias
UMLS CUI 2011AA
C0030054
SNOMED CT 2011_0131
24099007
LOINC Version 232
MTHU002757
Drains, Drain device
Description

DRAINS

Data type

string

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

PAIN MANAGEMENT

Data type

string

Alias
UMLS CUI 2011AA
C0002766
SNOMED CT 2011_0131
278414003
MedDRA 14.1
10056350
LOINC Version 232
MTHU031888
Respiratory Therapy (RT), Respiratory care
Description

MED RT

Data type

string

Alias
UMLS CUI 2011AA
C0035239
SNOMED CT 2011_0131
53950000
MedDRA 14.1
10059828
LOINC Version 232
MTHU015440
ICD-9-CM Version 2011
93.9
LAST TIME PATIENT WAS MEDICATED
Description

LAST TIME PATIENT WAS MEDICATED

Data type

time

Isolation
Description

ISOLATION

Data type

string

Alias
UMLS CUI 2011AA
C0205409
SNOMED CT 2011_0131
46651001
TYPE OF ISOLATION
Description

TYPE OF ISOLATION

Data type

string

DAILY WEIGHTS
Description

DAILY WEIGHTS

Data type

boolean

Alias
UMLS CUI 2011AA
C1305866
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Fall Risk, At risk for falling
Description

AT RISK FOR FALLS

Data type

boolean

Alias
UMLS CUI 2011AA
C1268740
SNOMED CT 2011_0131
129839007
ICD-10-CM Version 2010
Z91.81
ICD-9-CM Version 2011
V15.88
AT RISK FOR SKIN BREAKDOWN
Description

AT RISK FOR SKIN BREAKDOWN

Data type

string

Alias
UMLS CUI 2011AA
C0150077
SNOMED CT 2011_0131
247442005
MedDRA 14.1
10050204
LOINC Version 232
MTHU013438
Physical restraints, Physical restraint equipment
Description

RESTRAINTS

Data type

string

Alias
UMLS CUI 2011AA
C0337184
SNOMED CT 2011_0131
57395004
LOINC Version 232
MTHU032305
Date/Time of Restraints order:
Description

Date/Time of Restraints order:

Data type

date

SPECIAL PRECAUTIONS
Description

SPECIAL PRECAUTIONS

Data type

string

Alias
UMLS CUI 2011AA
C1882442
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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
Transfer assessment
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
DOCTOR
Item
Treating Physician, Treating Doctor
string
C1710470 (UMLS CUI 2011AA)
Admission Date
Item
Date of admission
date
C1302393 (UMLS CUI 2011AA)
399423000 (SNOMED CT 2011_0131)
MTHU029790 (LOINC Version 232)
FAMILY NOTIFIED
Item
FAMILY NOTIFIED
boolean
BELONGINGS WITH PATIENT
Item
BELONGINGS WITH PATIENT
boolean
MEDICATIONS WITH PATIENT
Item
MEDICATIONS WITH PATIENT
boolean
IV MEDICATIONS WITH PATIENT
Item
IV MEDICATIONS WITH PATIENT
boolean
PENDING LABS
Item
PENDING LABS
string
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)
Respiratory rate
Item
Respiratory Rate (/min)
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)
DATE OF SURGERY
Item
Date surgery
date
MTHU019327 (LOINC Version 232)
C1628561 (UMLS CUI-1)
CODE STATUS
Item
CODE STATUS
string
DATE CODE STATUS ORDERED
Item
DATE CODE STATUS ORDERED
date
REASON FOR TRANSFER
Item
REASON FOR TRANSFER
string
C1547731 (UMLS CUI 2011AA)
MTHU019076 (LOINC Version 232)
MODE OF TRANSFER
Item
Mode of transfer
string
C1718076 (UMLS CUI 2011AA)
MTHU021155 (LOINC Version 232)
LEVEL OF FUNCTION
Item
Functional Status, Level of function
string
C0598463 (UMLS CUI 2011AA)
MTHU027728 (LOINC Version 232)
Mental Status
Item
Mental Status, Mental State
string
C0278060 (UMLS CUI 2011AA)
36456004 (SNOMED CT 2011_0131)
MTHU001424 (LOINC Version 232)
MTHU117157 (CTCAE 1105E)
Level of Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
Activities of Daily Living
Item
Activities of Daily Living (ADL), Activities of everyday life
string
C0001288 (UMLS CUI 2011AA)
129025006 (SNOMED CT 2011_0131)
DIET
Item
Diet
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Tube Feeding via @ with @ strength of @
Item
Tube Feeding via @ with @ strength of @
string
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Last residual amount was @ CC'S and it was checked at @
Item
Last residual amount was @ CC'S and it was checked at @
string
Item Group
IV Therapy
C1411942 (UMLS CUI-1)
IV THERAPY
Item
intravenous therapy
string
C1411942 (UMLS CUI 2011AA)
Catheter Size
Item
Size of catheter
string
C0449963 (UMLS CUI 2011AA)
260967009 (SNOMED CT 2011_0131)
LOCATION
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
IV Fluid
Item
Intravenous fluid, Fluid for intravenous administration
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
LEFT TO COUNT [ml]
Item
LEFT TO COUNT [ml]
integer
Rate: @ ml/hr
Item
Rate: @ ml/hr
integer
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
CENTRAL LINE PORT
Item
Central venous catheter (CVC), Central venous line
string
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
IV Fluid
Item
Intravenous fluid, Fluid for intravenous administration
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Item
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
string
C0030548, C0023779 (UMLS CUI 2011AA)
225372007, 70106000 (SNOMED CT 2011_0131)
10044107 (MedDRA 14.1)
MTHU014331, MTHU003688 (LOINC Version 232)
99.15 (ICD-9-CM Version 2011)
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
SITE CHANGE DUE
Item
SITE CHANGE DUE
date
IV REASSESSMENT
Item
IV REASSESSMENT
string
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
NARRATIVE
Item
NARRATIVE
string
Item Group
Wound
C0043250 (UMLS CUI-1)
WOUND CARE
Item
WOUND CARE
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
SITE: LAST DRESSING CHANGE
Item
SITE: LAST DRESSING CHANGE
string
Item Group
ELIMINATION
C0221102 (UMLS CUI-1)
Date of last bowel movement
Item
Date of last bowel movement
date
C0011135 (UMLS CUI 2011AA)
39211005 (SNOMED CT 2011_0131)
Is the patient incontinent of stool?
Item
Is the patient incontinent of stool?
string
C0015732 (UMLS CUI 2011AA)
72042002 (SNOMED CT 2011_0131)
10016092 (MedDRA 14.1)
MTHU013375 (LOINC Version 232)
R15 (ICD-10-CM Version 2010)
787.6 (ICD-9-CM Version 2011)
E10693 (CTCAE 1105E)
Is the patient incontinent of urine?
Item
Is the patient incontinent of urine?
string
C0042024 (UMLS CUI 2011AA)
165232002 (SNOMED CT 2011_0131)
10046543 (MedDRA 14.1)
R32 (ICD-10-CM Version 2010)
788.3 (ICD-9-CM Version 2011)
E13042 (CTCAE 1105E)
Item Group
OTHER CARE
OXYGEN
Item
O2, Oxygen
string
C0030054 (UMLS CUI 2011AA)
24099007 (SNOMED CT 2011_0131)
MTHU002757 (LOINC Version 232)
DRAINS
Item
Drains, Drain device
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
PAIN MANAGEMENT
Item
Pain Therapy
string
C0002766 (UMLS CUI 2011AA)
278414003 (SNOMED CT 2011_0131)
10056350 (MedDRA 14.1)
MTHU031888 (LOINC Version 232)
MED RT
Item
Respiratory Therapy (RT), Respiratory care
string
C0035239 (UMLS CUI 2011AA)
53950000 (SNOMED CT 2011_0131)
10059828 (MedDRA 14.1)
MTHU015440 (LOINC Version 232)
93.9 (ICD-9-CM Version 2011)
LAST TIME PATIENT WAS MEDICATED
Item
LAST TIME PATIENT WAS MEDICATED
time
ISOLATION
Item
Isolation
string
C0205409 (UMLS CUI 2011AA)
46651001 (SNOMED CT 2011_0131)
TYPE OF ISOLATION
Item
TYPE OF ISOLATION
string
DAILY WEIGHTS
Item
DAILY WEIGHTS
boolean
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
AT RISK FOR FALLS
Item
Fall Risk, At risk for falling
boolean
C1268740 (UMLS CUI 2011AA)
129839007 (SNOMED CT 2011_0131)
Z91.81 (ICD-10-CM Version 2010)
V15.88 (ICD-9-CM Version 2011)
AT RISK FOR SKIN BREAKDOWN
Item
AT RISK FOR SKIN BREAKDOWN
string
C0150077 (UMLS CUI 2011AA)
247442005 (SNOMED CT 2011_0131)
10050204 (MedDRA 14.1)
MTHU013438 (LOINC Version 232)
RESTRAINTS
Item
Physical restraints, Physical restraint equipment
string
C0337184 (UMLS CUI 2011AA)
57395004 (SNOMED CT 2011_0131)
MTHU032305 (LOINC Version 232)
Date/Time of Restraints order:
Item
Date/Time of Restraints order:
date
SPECIAL PRECAUTIONS
Item
SPECIAL PRECAUTIONS
string
C1882442 (UMLS CUI 2011AA)
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