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
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
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
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)
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)