ID

11252

Beskrivning

Form from HIS OpenVista

Nyckelord

Versioner (5)
  1. 2012-03-09 2012-03-09 -
  2. 2014-08-07 2014-08-07 - Martin Dugas
  3. 2014-08-09 2014-08-09 - Martin Dugas
  4. 2014-08-11 2014-08-11 - Martin Dugas
  5. 2015-06-26 2015-06-26 - Martin Dugas
Uppladdad den

26 juni 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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PHYSICAL THERAPY INITIAL EVALUATION

Tysk Engelsk

HIS

1 Formulär  
  1. StudyEvent: HIS
    1. HIS
General Info
Beskrivning

General Info

Alias
UMLS CUI-1
C1508263
PHYSICAL THERAPY ORDER
Beskrivning

PHYSICAL THERAPY ORDER

Datatyp

text

Alias
UMLS CUI-1
C0949766
operative procedures
Beskrivning

SURGERY

Datatyp

string

Alias
UMLS CUI 2011AA
C0038895
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
Beskrivning

HISTORY OF PRESENT ILLNESS WITH ONSET DATE

Datatyp

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
UMLS CUI 2011AA
C0332162
SNOMED CT 2011_0131
77374008
SOCIAL/HEALTH HABITS(PAST & CURRENT)
Beskrivning

SOCIAL/HEALTH HABITS(PAST & CURRENT)

Alkohol-Abusus
Beskrivning

Alcohol

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0085762
SNOMED CT 2011_0131
15167005
MedDRA 14.1
10001584
LOINC Version 232
LP36309-0
ICD-10-CM Version 2010
F10.1
ICD-9-CM Version 2011
305.0
Raucher
Beskrivning

Smoking

Datatyp

boolean

Alias
UMLS CUI-1
C1519386
Living Situation, Dwelling
Beskrivning

Living Situation, Dwelling

Assisted Living, Residential Care
Beskrivning

Assisted Living

Datatyp

boolean

Alias
UMLS CUI 2011AA
C1456630
Home (Lives Alone)
Beskrivning

Home (Lives Alone)

Datatyp

boolean

Home with parent(s)
Beskrivning

Home with parent(s)

Datatyp

boolean

Home w/Significant Other
Beskrivning

Home w/Significant Other

Datatyp

boolean

Home w/Spouse
Beskrivning

Home w/Spouse

Datatyp

boolean

Home w/Family (Children)
Beskrivning

Home w/Family (Children)

Datatyp

boolean

Home w/Friend (Caretaker)
Beskrivning

Home w/Friend (Caretaker)

Datatyp

boolean

Dependent in ADLs
Beskrivning

Dependent in ADLs

Datatyp

boolean

Independent in ADLs
Beskrivning

Independent in ADLs

Datatyp

boolean

Pflegeheim
Beskrivning

Nursing Home

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0028688
SNOMED CT 2011_0131
42665001
LOINC Version 232
MTHU015917
HL7 V3 2006_05
N
Altersheim
Beskrivning

Retirement Center/ Assisted Living Facility

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0872103
HL7 V3 2006_05
310400000X
Requires Assistance with ADLs
Beskrivning

Requires Assistance with ADLs

Datatyp

boolean

Other
Beskrivning

Other

Datatyp

boolean

Stairs to enter
Beskrivning

Stairs to enter

Datatyp

boolean

Stairs indoors
Beskrivning

Stairs indoors

Datatyp

boolean

REMAIN ON FIRST FLOOR
Beskrivning

REMAIN ON FIRST FLOOR

Datatyp

boolean

OTHER OBSTACLES OF CONCERN
Beskrivning

OTHER OBSTACLES OF CONCERN

Datatyp

string

Anamnese
Beskrivning

Anamnese

Alias
UMLS CUI-1
C0262926
PREMORBID FUNCTIONAL STATUS
Beskrivning

PREMORBID FUNCTIONAL STATUS

Datatyp

string

Familienanamnese
Beskrivning

Family history

Datatyp

text

Alias
SNOMED CT 2011_0131
57177007
UMLS CUI-1
C0241889
MEDICAL/SURGICAL HISTORY
Beskrivning

Medical/surgical history

Datatyp

text

Alias
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
SNOMED CT 2011_0131
161615003
UMLS CUI-1
C0262926
UMLS CUI-2
C0455610
MEDICATIONS REVIEWED
Beskrivning

MEDICATIONS REVIEWED

Datatyp

boolean

PERTINENT MEDICATIONS AFFECTING THERAPY
Beskrivning

PERTINENT MEDICATIONS AFFECTING THERAPY

Datatyp

string

CLINICAL TESTS
Beskrivning

CLINICAL TESTS

Datatyp

string

I.D. VERIFIED BY
Beskrivning

I.D. VERIFIED BY

Datatyp

string

I.D. VERIFICATION
Beskrivning

I.D. VERIFICATION

Datatyp

string

Anamnese der Organsysteme
Beskrivning

Anamnese der Organsysteme

Alias
UMLS CUI-1
C0489633
Größe
Beskrivning

Height

Datatyp

float

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

Weight

Datatyp

float

Måttenheter
  • kg
Alias
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
UMLS CUI-1
C0005910
kg
Pulsfrequenz
Beskrivning

Pulse Rate

Datatyp

integer

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

Respiration Rate

Datatyp

integer

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

Blood Pressure

Datatyp

integer

Måttenheter
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
Ödem
Beskrivning

Edema

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0013604
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
Ankle Edema (L/R)
Beskrivning

Ankle Edema

Datatyp

text

Alias
SNOMED CT 2011_0131
344001
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
UMLS CUI-1
C0235439
Foot Edema (L/R)
Beskrivning

Foot Edema

Datatyp

text

Alias
SNOMED CT 2011_0131
56459004
LOINC Version 232
MTHU002679
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
UMLS CUI-1
C0574002
Hand Edema (L/R)
Beskrivning

Hand Edema

Datatyp

text

Alias
UMLS CUI-1
C0239819
Knee Edema (L/R)
Beskrivning

Knee Edema

Datatyp

text

Alias
UMLS CUI-1
C0522045
Beinödeme
Beskrivning

Leg Edema

Datatyp

text

Alias
SNOMED CT 2011_0131
102574007
MedDRA 14.1
10024127
UMLS CUI-1
C0235886
INTEGUMENTARY within normal limits
Beskrivning

INTEGUMENTARY WNL

Datatyp

boolean

Alias
UMLS CUI-1
C0558145
Haut
Beskrivning

Integument

Datatyp

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
MUSCULOSKELETAL WNL
Beskrivning

MUSCULOSKELETAL WNL

Datatyp

boolean

Alias
UMLS CUI-1
C0430745
Muskuloskeletales System
Beskrivning

Musculoskeletal

Datatyp

text

Alias
SNOMED CT 2011_0131
26107004
LOINC Version 232
MTHU001411
UMLS CUI-1
C0026860
ROM/STRENGTH
Beskrivning

ROM/STRENGTH

Datatyp

string

NEUROMUSCULAR WNL
Beskrivning

NEUROMUSCULAR WNL

Datatyp

boolean

Neuromuscular
Beskrivning

Neuromuscular

Datatyp

text

Alias
UMLS CUI-1
C1979768
Gang
Beskrivning

GAIT

Datatyp

text

Alias
SNOMED CT 2011_0131
63448001
LOINC Version 232
MTHU015039
UMLS CUI-1
C0016928
BALANCE
Beskrivning

BALANCE

Datatyp

text

Alias
UMLS CUI-1
C0560184
MOTOR CONTROL
Beskrivning

MOTOR CONTROL

Datatyp

text

Alias
UMLS CUI-1
C0517961
COMMUNICATION WNL
Beskrivning

COMMUNICATION WNL

Datatyp

boolean

COMMUNICATION
Beskrivning

COMMUNICATION

Datatyp

text

Alias
UMLS CUI-1
C0009452
language ability, verbal ability
Beskrivning

LANGUAGE

Datatyp

string

Alias
UMLS CUI 2011AA
C1145677
Orientierung
Beskrivning

ORIENTATION

Datatyp

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
Gedächtnisverlust
Beskrivning

Memory loss

Datatyp

string

Alias
UMLS CUI 2011AA
C0751295
MedDRA 14.1
10027176
LOINC Version 232
MTHU013522
ICD-9-CM Version 2011
780.93
EMOTIONAL/BEHAVIORAL RESPONSES WNL
Beskrivning

EMOTIONAL/BEHAVIORAL RESPONSES WNL

Datatyp

boolean

Emotional / Behavioral responses
Beskrivning

Emotional / Behavioral responses

Datatyp

string

LEARNING BARRIERS
Beskrivning

LEARNING BARRIERS

Datatyp

boolean

Hearing impaired
Beskrivning

Hearing impaired

Datatyp

boolean

Alias
UMLS CUI-1
C1384666
Language/Needs interpreter
Beskrivning

Language/Needs interpreter

Datatyp

boolean

unable to read
Beskrivning

unable to read

Datatyp

boolean

Alias
UMLS CUI-1
C0586741
Vision impaired
Beskrivning

Vision impaired

Datatyp

boolean

Alias
UMLS CUI-1
C3665347
EDUCATION NEEDS
Beskrivning

EDUCATION NEEDS

Datatyp

boolean

Education ADLs
Beskrivning

Education ADLs

Datatyp

boolean

Alias
SNOMED CT 2011_0131
129025006
UMLS CUI-1
C0013622
UMLS CUI-2
C0001288
Education Disease
Beskrivning

Education Disease

Datatyp

boolean

Alias
SNOMED CT 2011_0131
64572001
UMLS CUI-1
C0013622
UMLS CUI-2
C0012634
Education Equipment
Beskrivning

Education Equipment

Datatyp

boolean

Education Exercise Program
Beskrivning

Education Exercise Program

Datatyp

boolean

Education Safety
Beskrivning

Education Safety

Datatyp

boolean

Education Transfers
Beskrivning

Education Transfers

Datatyp

boolean

other Education needs
Beskrivning

other Education needs

Datatyp

string

KEYS TO TEST AND MEASURES
Beskrivning

KEYS TO TEST AND MEASURES

AEROBIC CAPACITY/ENDURANCE
Beskrivning

AEROBIC CAPACITY/ENDURANCE

Datatyp

string

AROUSAL, ATTENTION, AND COGNITION
Beskrivning

AROUSAL, ATTENTION, AND COGNITION

Datatyp

string

ASSISTIVE AND ADAPTIVE EQUIPMENT
Beskrivning

ASSISTIVE AND ADAPTIVE EQUIPMENT

Datatyp

string

CIRCULATION
Beskrivning

CIRCULATION

Datatyp

string

GAIT, LOCOMOTION, AND BALANCE
Beskrivning

GAIT, LOCOMOTION, AND BALANCE

Datatyp

string

INTEGUMENTARY INTEGRITY
Beskrivning

INTEGUMENTARY INTEGRITY

Datatyp

string

MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
Beskrivning

MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)

Datatyp

string

MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
Beskrivning

MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)

Datatyp

string

NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
Beskrivning

NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION

Datatyp

string

ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
Beskrivning

ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES

Datatyp

string

Schmerz
Beskrivning

PAIN

Datatyp

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
POSTURE
Beskrivning

POSTURE

Datatyp

text

Alias
UMLS CUI-1
C1262869
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
Beskrivning

RANGE OF MOTION (INCLUDING MUSCLE LENGTH)

Datatyp

string

REFLEX INTEGRITY
Beskrivning

REFLEX INTEGRITY

Datatyp

text

Alias
UMLS CUI-1
C0596002
SENSORY INTEGRITY
Beskrivning

SENSORY INTEGRITY

Datatyp

text

Alias
UMLS CUI-1
C2735300
SELF CARE AND HOME MANAGEMENT
Beskrivning

SELF CARE AND HOME MANAGEMENT

Datatyp

string

WORK REINTEGRATION
Beskrivning

WORK REINTEGRATION

Datatyp

string

EVALUATION
Beskrivning

EVALUATION

Datatyp

string

Diagnose
Beskrivning

Diagnose

Alias
UMLS CUI-1
C0011900
Cardiovascular Pattern(s)
Beskrivning

Cardiovascular Pattern(s)

Datatyp

boolean

Integumentary Pattern(s)
Beskrivning

Integumentary Pattern(s)

Datatyp

boolean

Musculoskeletal Pattern(s)
Beskrivning

Musculoskeletal Pattern(s)

Datatyp

boolean

Neuromuscular Pattern(s)
Beskrivning

Neuromuscular Pattern(s)

Datatyp

boolean

Diagnose
Beskrivning

Diagnosis text

Datatyp

string

Alias
UMLS CUI 2011AA
C0011900
SNOMED CT 2011_0131
439401001
LOINC Version 232
MTHU008876
PROGNOSIS, Goals, Interventions, Plan
Beskrivning

PROGNOSIS, Goals, Interventions, Plan

Prognose
Beskrivning

Prognosis

Datatyp

string

Alias
UMLS CUI 2011AA
C0033325
SNOMED CT 2011_0131
20481000
Ziele
Beskrivning

Goals

Datatyp

string

Alias
UMLS CUI 2011AA
C0018017
SNOMED CT 2011_0131
410518001
LOINC Version 232
MTHU036445
Interventions
Beskrivning

Interventions

Datatyp

text

Alias
UMLS CUI-1
C0184661
TODAYS
Beskrivning

TODAYS

Datatyp

string

Educated - family
Beskrivning

Educated - family

Datatyp

boolean

Educated - patient
Beskrivning

Educated - patient

Datatyp

boolean

Educated - significant other
Beskrivning

Educated - significant other

Datatyp

boolean

Educated - returns Demonstration
Beskrivning

Educated - returns Demonstration

Datatyp

boolean

Educated - Verbalizes understanding
Beskrivning

Educated - Verbalizes understanding

Datatyp

boolean

DISCHARGE PLANS
Beskrivning

DISCHARGE PLANS

Datatyp

text

Alias
UMLS CUI-1
C2735970
Discharge status
Beskrivning

DISCHARGE STATUS

Datatyp

string

Alias
UMLS CUI 2011AA
C0586514
SNOMED CT 2011_0131
309039003
LOINC Version 232
MTHU031549
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
Beskrivning

FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE

Datatyp

string

Tillbaka till toppen

Similar models

HIS

1 Formulär
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
General Info
C1508263 (UMLS CUI-1)
PHYSICAL THERAPY ORDER
Item
PHYSICAL THERAPY ORDER
text
C0949766 (UMLS CUI-1)
SURGERY
Item
operative procedures
string
C0038895 (UMLS CUI 2011AA)
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
Item
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
C0332162 (UMLS CUI 2011AA)
77374008 (SNOMED CT 2011_0131)
Item Group
SOCIAL/HEALTH HABITS(PAST & CURRENT)
Alcohol
Item
Alkohol-Abusus
boolean
C0085762 (UMLS CUI 2011AA)
15167005 (SNOMED CT 2011_0131)
10001584 (MedDRA 14.1)
LP36309-0 (LOINC Version 232)
F10.1 (ICD-10-CM Version 2010)
305.0 (ICD-9-CM Version 2011)
Smoking
Item
Raucher
boolean
C1519386 (UMLS CUI-1)
Item Group
Living Situation, Dwelling
Assisted Living
Item
Assisted Living, Residential Care
boolean
C1456630 (UMLS CUI 2011AA)
Home (Lives Alone)
Item
Home (Lives Alone)
boolean
Home with parent(s)
Item
Home with parent(s)
boolean
Home w/Significant Other
Item
Home w/Significant Other
boolean
Home w/Spouse
Item
Home w/Spouse
boolean
Home w/Family (Children)
Item
Home w/Family (Children)
boolean
Home w/Friend (Caretaker)
Item
Home w/Friend (Caretaker)
boolean
Dependent in ADLs
Item
Dependent in ADLs
boolean
Independent in ADLs
Item
Independent in ADLs
boolean
Nursing Home
Item
Pflegeheim
boolean
C0028688 (UMLS CUI 2011AA)
42665001 (SNOMED CT 2011_0131)
MTHU015917 (LOINC Version 232)
N (HL7 V3 2006_05)
Retirement Center/ Assisted Living Facility
Item
Altersheim
boolean
C0872103 (UMLS CUI 2011AA)
310400000X (HL7 V3 2006_05)
Requires Assistance with ADLs
Item
Requires Assistance with ADLs
boolean
Other
Item
Other
boolean
Stairs to enter
Item
Stairs to enter
boolean
Stairs indoors
Item
Stairs indoors
boolean
REMAIN ON FIRST FLOOR
Item
REMAIN ON FIRST FLOOR
boolean
OTHER OBSTACLES OF CONCERN
Item
OTHER OBSTACLES OF CONCERN
string
Item Group
Anamnese
C0262926 (UMLS CUI-1)
PREMORBID FUNCTIONAL STATUS
Item
PREMORBID FUNCTIONAL STATUS
string
Family history
Item
Familienanamnese
text
57177007 (SNOMED CT 2011_0131)
C0241889 (UMLS CUI-1)
Medical/surgical history
Item
MEDICAL/SURGICAL HISTORY
text
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
161615003 (SNOMED CT 2011_0131)
C0262926 (UMLS CUI-1)
C0455610 (UMLS CUI-2)
MEDICATIONS REVIEWED
Item
MEDICATIONS REVIEWED
boolean
PERTINENT MEDICATIONS AFFECTING THERAPY
Item
PERTINENT MEDICATIONS AFFECTING THERAPY
string
CLINICAL TESTS
Item
CLINICAL TESTS
string
I.D. VERIFIED BY
Item
I.D. VERIFIED BY
string
I.D. VERIFICATION
Item
I.D. VERIFICATION
string
Item Group
Anamnese der Organsysteme
C0489633 (UMLS CUI-1)
Height
Item
Größe
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Gewicht
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (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)
Edema
Item
Ödem
boolean
C0013604 (UMLS CUI 2011AA)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
Item
Ankle Edema (L/R)
text
344001 (SNOMED CT 2011_0131)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
C0235439 (UMLS CUI-1)
Ankle Edema
Code List
Ankle Edema (L/R)
CL Item
 (L)
C0205091 (UMLS CUI-1)
CL Item
 (R)
C0205090 (UMLS CUI-1)
Item
Foot Edema (L/R)
text
56459004 (SNOMED CT 2011_0131)
MTHU002679 (LOINC Version 232)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
C0574002 (UMLS CUI-1)
Ankle Edema
Code List
Foot Edema (L/R)
CL Item
 (L)
C0205091 (UMLS CUI-1)
CL Item
 (R)
C0205090 (UMLS CUI-1)
Item
Hand Edema (L/R)
text
C0239819 (UMLS CUI-1)
Ankle Edema
Code List
Hand Edema (L/R)
CL Item
 (L)
C0205091 (UMLS CUI-1)
CL Item
 (R)
C0205090 (UMLS CUI-1)
Item
Knee Edema (L/R)
text
C0522045 (UMLS CUI-1)
Ankle Edema
Code List
Knee Edema (L/R)
CL Item
 (L)
C0205091 (UMLS CUI-1)
CL Item
 (R)
C0205090 (UMLS CUI-1)
Item
Beinödeme
text
102574007 (SNOMED CT 2011_0131)
10024127 (MedDRA 14.1)
C0235886 (UMLS CUI-1)
Ankle Edema
Code List
Beinödeme
CL Item
 (L)
C0205091 (UMLS CUI-1)
CL Item
 (R)
C0205090 (UMLS CUI-1)
INTEGUMENTARY WNL
Item
INTEGUMENTARY within normal limits
boolean
C0558145 (UMLS CUI-1)
Integument
Item
Haut
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
MUSCULOSKELETAL WNL
Item
MUSCULOSKELETAL WNL
boolean
C0430745 (UMLS CUI-1)
Musculoskeletal
Item
Muskuloskeletales System
text
26107004 (SNOMED CT 2011_0131)
MTHU001411 (LOINC Version 232)
C0026860 (UMLS CUI-1)
ROM/STRENGTH
Item
ROM/STRENGTH
string
NEUROMUSCULAR WNL
Item
NEUROMUSCULAR WNL
boolean
Neuromuscular
Item
Neuromuscular
text
C1979768 (UMLS CUI-1)
GAIT
Item
Gang
text
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
C0016928 (UMLS CUI-1)
BALANCE
Item
BALANCE
text
C0560184 (UMLS CUI-1)
MOTOR CONTROL
Item
MOTOR CONTROL
text
C0517961 (UMLS CUI-1)
COMMUNICATION WNL
Item
COMMUNICATION WNL
boolean
COMMUNICATION
Item
COMMUNICATION
text
C0009452 (UMLS CUI-1)
LANGUAGE
Item
language ability, verbal ability
string
C1145677 (UMLS CUI 2011AA)
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
ORIENTATION
Code List
Orientierung
CL Item
Oriented (1)
CL Item
Disoriented (2)
Item
Gedächtnisverlust
string
C0751295 (UMLS CUI 2011AA)
10027176 (MedDRA 14.1)
MTHU013522 (LOINC Version 232)
780.93 (ICD-9-CM Version 2011)
Memory loss
Code List
Gedächtnisverlust
CL Item
no memory loss (1)
CL Item
Long term memory loss (2)
CL Item
Recent memory loss (3)
EMOTIONAL/BEHAVIORAL RESPONSES WNL
Item
EMOTIONAL/BEHAVIORAL RESPONSES WNL
boolean
Emotional / Behavioral responses
Item
Emotional / Behavioral responses
string
LEARNING BARRIERS
Item
LEARNING BARRIERS
boolean
Hearing impaired
Item
Hearing impaired
boolean
C1384666 (UMLS CUI-1)
Language/Needs interpreter
Item
Language/Needs interpreter
boolean
unable to read
Item
unable to read
boolean
C0586741 (UMLS CUI-1)
Vision impaired
Item
Vision impaired
boolean
C3665347 (UMLS CUI-1)
EDUCATION NEEDS
Item
EDUCATION NEEDS
boolean
Education ADLs
Item
Education ADLs
boolean
129025006 (SNOMED CT 2011_0131)
C0013622 (UMLS CUI-1)
C0001288 (UMLS CUI-2)
Education Disease
Item
Education Disease
boolean
64572001 (SNOMED CT 2011_0131)
C0013622 (UMLS CUI-1)
C0012634 (UMLS CUI-2)
Education Equipment
Item
Education Equipment
boolean
Education Exercise Program
Item
Education Exercise Program
boolean
Education Safety
Item
Education Safety
boolean
Education Transfers
Item
Education Transfers
boolean
other Education needs
Item
other Education needs
string
Item Group
KEYS TO TEST AND MEASURES
AEROBIC CAPACITY/ENDURANCE
Item
AEROBIC CAPACITY/ENDURANCE
string
AROUSAL, ATTENTION, AND COGNITION
Item
AROUSAL, ATTENTION, AND COGNITION
string
ASSISTIVE AND ADAPTIVE EQUIPMENT
Item
ASSISTIVE AND ADAPTIVE EQUIPMENT
string
CIRCULATION
Item
CIRCULATION
string
GAIT, LOCOMOTION, AND BALANCE
Item
GAIT, LOCOMOTION, AND BALANCE
string
INTEGUMENTARY INTEGRITY
Item
INTEGUMENTARY INTEGRITY
string
MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
Item
MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
string
MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
Item
MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
string
NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
Item
NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
string
ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
Item
ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
string
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)
POSTURE
Item
POSTURE
text
C1262869 (UMLS CUI-1)
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
Item
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
string
REFLEX INTEGRITY
Item
REFLEX INTEGRITY
text
C0596002 (UMLS CUI-1)
SENSORY INTEGRITY
Item
SENSORY INTEGRITY
text
C2735300 (UMLS CUI-1)
SELF CARE AND HOME MANAGEMENT
Item
SELF CARE AND HOME MANAGEMENT
string
WORK REINTEGRATION
Item
WORK REINTEGRATION
string
EVALUATION
Item
EVALUATION
string
Item Group
Diagnose
C0011900 (UMLS CUI-1)
Cardiovascular Pattern(s)
Item
Cardiovascular Pattern(s)
boolean
Integumentary Pattern(s)
Item
Integumentary Pattern(s)
boolean
Musculoskeletal Pattern(s)
Item
Musculoskeletal Pattern(s)
boolean
Neuromuscular Pattern(s)
Item
Neuromuscular Pattern(s)
boolean
Diagnosis text
Item
Diagnose
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
Item Group
PROGNOSIS, Goals, Interventions, Plan
Prognosis
Item
Prognose
string
C0033325 (UMLS CUI 2011AA)
20481000 (SNOMED CT 2011_0131)
Goals
Item
Ziele
string
C0018017 (UMLS CUI 2011AA)
410518001 (SNOMED CT 2011_0131)
MTHU036445 (LOINC Version 232)
Interventions
Item
Interventions
text
C0184661 (UMLS CUI-1)
TODAYS
Item
TODAYS
string
Educated - family
Item
Educated - family
boolean
Educated - patient
Item
Educated - patient
boolean
Educated - significant other
Item
Educated - significant other
boolean
Educated - returns Demonstration
Item
Educated - returns Demonstration
boolean
Educated - Verbalizes understanding
Item
Educated - Verbalizes understanding
boolean
DISCHARGE PLANS
Item
DISCHARGE PLANS
text
C2735970 (UMLS CUI-1)
DISCHARGE STATUS
Item
Discharge status
string
C0586514 (UMLS CUI 2011AA)
309039003 (SNOMED CT 2011_0131)
MTHU031549 (LOINC Version 232)
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
Item
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
string
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