ID

11639

Beschreibung

Form from HIS OpenVistA

Stichworte

  1. 10.02.12 10.02.12 -
  2. 09.07.15 09.07.15 - Martin Dugas
  3. 28.08.15 28.08.15 - Martin Dugas
Hochgeladen am

9. Juli 2015

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy

Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

CARDIAC REHAB CONSULT RESULTS INTERDISCIPLINARY NOTE

  1. StudyEvent: HIS
    1. HIS
Date, Diagnosis, BMI
Beschreibung

Date, Diagnosis, BMI

DATE REFERRAL RECEIVED
Beschreibung

DATE REFERRAL RECEIVED

Datentyp

date

ADMISSION DATE TO CARDIAC REHABILITATION
Beschreibung

ADMISSION DATE TO CARDIAC REHABILITATION

Datentyp

date

Diagnose
Beschreibung

Diagnosis

Datentyp

string

Alias
UMLS CUI
C0011900
SNOMED CT 2010_0731
439401001
LOINC Version 232
MTHU008876
Gewicht
Beschreibung

Current Weight

Datentyp

string

Alias
UMLS CUI
C1305866
SNOMED CT 2010_0731
107647005
MedDRA 13.1
10047890
LOINC Version 232
LP18015-5
Größe
Beschreibung

Current Height

Datentyp

string

Alias
UMLS CUI
C0489786
LOINC Version 232
MTHU005354
BMI
Beschreibung

BMI

Datentyp

string

Alias
UMLS CUI
C1305855
SNOMED CT 2010_0731
140075008
MedDRA 13.1
10005894
LOINC Version 232
LP35925-4
SYMPTOMS
Beschreibung

SYMPTOMS

Alias
UMLS CUI-1
C1457887
SYMPTOM(S) ON ADMISSION (Arm/Shoulder discomfort, Chest discomfort, Diaphoresis and sweating, Dizziness, Dyspnea/SOB, Fatigue, Indigestion, Nausea/Vomiting, Neck/Jaw discomfort, Other)
Beschreibung

SYMPTOM(S) ON ADMISSION

Datentyp

string

PAST CARDIAC HISTORY
Beschreibung

PAST CARDIAC HISTORY

Alias
UMLS CUI-1
C0559157
PAST CARDIAC HISTORY
Beschreibung

PAST CARDIAC HISTORY

Datentyp

text

Alias
UMLS CUI-1
C0559157
PAST Medical HISTORY
Beschreibung

PAST Medical HISTORY

Alias
UMLS CUI-1
C0262926
Akutes Nierenversagen/Dialyse
Beschreibung

ARF/Dialysis

Datentyp

string

Arthritis
Beschreibung

Arthritis

Datentyp

string

Alias
UMLS CUI
C0003864
SNOMED CT 2010_0731
3723001
MedDRA 13.1
10003246
LOINC Version 232
MTHU020793
ICD-10-CM Version 2010
M19.90
ICD-9-CM Version 2011
716.9
CTCAE Version 4.03
E12378
Asthma
Beschreibung

Asthma

Datentyp

string

Alias
UMLS CUI
C0004096
SNOMED CT 2010_0731
195967001
MedDRA 13.1
10003553
LOINC Version 232
MTHU020815
ICD-10-CM Version 2010
J45
ICD-9-CM Version 2011
493
Krebs
Beschreibung

Cancer

Datentyp

string

Alias
UMLS CUI
C0006826
SNOMED CT 2010_0731
363346000
MedDRA 13.1
10028997
LOINC Version 232
MTHU010328
ICD-10-CM Version 2010
C00-C96
COPD
Beschreibung

COPD

Datentyp

string

Alias
UMLS CUI
C0024117
SNOMED CT 2010_0731
13645005
MedDRA 13.1
10009033
ICD-10-CM Version 2010
J44.9
ICD-9-CM Version 2011
496
Depression
Beschreibung

Depression

Datentyp

string

Alias
UMLS CUI
C0011581
SNOMED CT 2010_0731
35489007
MedDRA 13.1
10012401
ICD-10-CM Version 2010
F32.9
Orthopedic Limitation
Beschreibung

Orthopedic Limitation

Datentyp

string

Schilddrüsenerkrankung
Beschreibung

Thyroid Disorder

Datentyp

string

Alias
UMLS CUI
C0040128
SNOMED CT 2010_0731
14304000
MedDRA 13.1
10043709
ICD-10-CM Version 2010
E00-E07
ICD-9-CM Version 2011
240-246.99
Other
Beschreibung

Other

Datentyp

string

History of Hypertension
Beschreibung

History of Hypertension

Datentyp

text

Alias
UMLS CUI-1
C0455527
History of Diabetes
Beschreibung

History of Diabetes

Datentyp

string

Cholesterol History
Beschreibung

Cholesterol History

Datentyp

string

LIPID VALUES THIS ADMISSION
Beschreibung

LIPID VALUES THIS ADMISSION

Datentyp

string

Körperliche Aktivität
Beschreibung

Physical Activity

Datentyp

string

Alias
UMLS CUI
C0026606
SNOMED CT 2010_0731
68130003
LOINC Version 232
MTHU017278
PERTINENT SOCIAL HISTORY
Beschreibung

PERTINENT SOCIAL HISTORY

Family Status
Beschreibung

Family Status

Datentyp

text

Alias
UMLS CUI-1
C0682315
PATIENT LIVES
Beschreibung

PATIENT LIVES

Datentyp

string

Beschäftigungsstatus
Beschreibung

Employment Status

Datentyp

string

Alias
UMLS CUI
C0242271
SNOMED CT 2010_0731
224362002
Familienanamnese
Beschreibung

Family History

Datentyp

string

Alias
UMLS CUI
C0241889
SNOMED CT 2010_0731
57177007
Stress
Beschreibung

Stress/ Psychological Concerns

Datentyp

string

Alias
UMLS CUI
C0038435
SNOMED CT 2010_0731
262188008
MedDRA 13.1
10042209
PATIENT APPEARS (Behavior)
Beschreibung

PATIENT APPEARS (Behavior)

Datentyp

string

Smoking History
Beschreibung

Smoking History

Raucher
Beschreibung

Uses tobacco products

Datentyp

text

Alias
UMLS CUI-1
C0543414
HOW MUCH Smoking
Beschreibung

HOW MUCH Smoking

Datentyp

text

Alias
UMLS CUI-1
C1822491
Quit at time of hospitalization
Beschreibung

Quit at time of hospitalization

Datentyp

string

Former smoker(not smoked more than 6 months)
Beschreibung

Former smoker(not smoked more than 6 months)

Datentyp

string

Quit smoking in
Beschreibung

Quit smoking in

Datentyp

date

Never Smoked
Beschreibung

Never Smoked

Datentyp

string

NARRATIVE
Beschreibung

NARRATIVE

Datentyp

string

Procedure Date and Results
Beschreibung

Procedure Date and Results

Herzkatheter
Beschreibung

CARDIAC CATHETERIZATION

Datentyp

string

Alias
UMLS CUI
C0018795
SNOMED CT 2010_0731
41976001
MedDRA 13.1
10007815
ICD-9-CM Version 2011
37.21
CARDIAC CATHETERIZATION DATE
Beschreibung

CARDIAC CATHETERIZATION DATE

Datentyp

string

Ejektionsfraktion (EF)
Beschreibung

Ejection Fraction

Datentyp

string

Alias
UMLS CUI
C0232174
SNOMED CT 2010_0731
70822001
LV FUNCTION
Beschreibung

LV FUNCTION

Datentyp

string

MARK WITH % OCCLUSIONS
Beschreibung

MARK WITH % OCCLUSIONS

Datentyp

string

LM
Beschreibung

LM

Datentyp

string

LAD
Beschreibung

LAD

Datentyp

string

DIAGONAL
Beschreibung

DIAGONAL

Datentyp

string

CX
Beschreibung

CX

Datentyp

string

ADDITIONAL COMMENTS
Beschreibung

ADDITIONAL COMMENTS

Datentyp

string

PTCI / STENT
Beschreibung

PTCI / STENT

Datentyp

string

PTCI DATE
Beschreibung

PTCI DATE

Datentyp

string

PTCA
Beschreibung

PTCA

Datentyp

text

Alias
UMLS CUI-1
C2936173
STENT
Beschreibung

STENT

Datentyp

text

Alias
UMLS CUI-1
C0038257
ATHERECTOMY
Beschreibung

ATHERECTOMY

Datentyp

string

IIB/IIA INHIBITOR
Beschreibung

IIB/IIA INHIBITOR

Datentyp

string

MARK WITH APPROPRIATE LETTER: PTCA-(P), STENT-(S), ATHERECTOMY-(A)
Beschreibung

MARK WITH APPROPRIATE LETTER: PTCA-(P), STENT-(S), ATHERECTOMY-(A)

Datentyp

string

LM
Beschreibung

LM

Datentyp

string

LAD
Beschreibung

LAD

Datentyp

text

Alias
UMLS CUI-1
C0226032
DIAGONAL
Beschreibung

DIAGONAL

Datentyp

string

CX
Beschreibung

CX

Datentyp

string

ADDITIONAL COMMENTS
Beschreibung

ADDITIONAL COMMENTS

Datentyp

string

SURGERY
Beschreibung

SURGERY

Datentyp

string

Koronare Bypassoperation
Beschreibung

CABG

Datentyp

string

Alias
UMLS CUI
C0010055
SNOMED CT 2010_0731
232717009
MedDRA 13.1
10011077
ICD-9-CM Version 2011
36.10
DATE CABG
Beschreibung

DATE CABG

Datentyp

date

MIDCAB
Beschreibung

MIDCAB

Datentyp

string

AVR
Beschreibung

AVR

Datentyp

string

MVR
Beschreibung

MVR

Datentyp

string

OTHER PROCEDURES
Beschreibung

OTHER PROCEDURES

Datentyp

string

CARDIOVASCULAR RISK FACTOR
Beschreibung

CARDIOVASCULAR RISK FACTOR

Datentyp

string

CORRELATE A NUMBER WITH GRAFT ORIGIN SITE
Beschreibung

CORRELATE A NUMBER WITH GRAFT ORIGIN SITE

Datentyp

string

DONOR AREA TO
Beschreibung

DONOR AREA TO

Datentyp

string

LIMA
Beschreibung

LIMA

Datentyp

string

RIMA
Beschreibung

RIMA

Datentyp

string

RADIAL
Beschreibung

RADIAL

Datentyp

string

SVG
Beschreibung

SVG

Datentyp

string

RPD
Beschreibung

RPD

Datentyp

string

PATIENT/FAMILY EDUCATION
Beschreibung

PATIENT/FAMILY EDUCATION

BOOKLET(S) GIVEN
Beschreibung

BOOKLET(S) GIVEN

Datentyp

string

DATE BOOKLET(S) given
Beschreibung

DATE BOOKLET(S) given

Datentyp

date

BOOKLET VERSIONS
Beschreibung

BOOKLET VERSIONS

Datentyp

string

VIDEO(S) SHOWN
Beschreibung

VIDEO(S) SHOWN

Datentyp

string

DATE VIDEO(S) shown
Beschreibung

DATE VIDEO(S) shown

Datentyp

string

VIDEO VERSION
Beschreibung

VIDEO VERSION

Datentyp

string

LEARNER
Beschreibung

LEARNER

Datentyp

string

PATIENT'S PHYSICAL READINESS TO LEARN
Beschreibung

PATIENT'S PHYSICAL READINESS TO LEARN

Datentyp

string

PSYCHOLOGICALLY WILLING TO LEARN
Beschreibung

PSYCHOLOGICALLY WILLING TO LEARN

Datentyp

string

EDUCATIONAL TOPICS: 1.Description of Cardiac Catheterization and site care, 2.Heart structure and function, 3.Myocardial Infarction symptoms and interventions, 4.Unstable Angina symptoms and interventons, 5.Congestive Heart Failure and importance of daily weights, 6.PTCI (Angioplasty,Stent), 7.Open Heart Surgery
Beschreibung

EDUCATIONAL TOPICS Heart Disease

Datentyp

string

EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION: 1.Tobacco Cessation, 2.Exercise guidelines, aerobic exercise for minimum of 30 minutes, 3.Dietary Modifications, 4.Stress Management, 5.Cholesterol and Triglycerides, 6.Diabetes Management, 7.Obesity, 8.Medication, 9.Hypertension
Beschreibung

EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION

Datentyp

string

DISCHARGE SPECIFIC INSTRUCTIONS: 1.Activity, 2.Site / Incision care, 3.Daily Weight, 4.Returning to work, 5.Driving, 6.Recurrent Chest Pain, 7.Psychosocial, 8.Coumadin, 9.Sex
Beschreibung

DISCHARGE SPECIFIC INSTRUCTIONS

Datentyp

string

CARDIAC REHAB NARRATIVE
Beschreibung

CARDIAC REHAB NARRATIVE

Datentyp

string

Ähnliche Modelle

  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
DATE REFERRAL RECEIVED
Item
DATE REFERRAL RECEIVED
date
ADMISSION DATE TO CARDIAC REHABILITATION
Item
ADMISSION DATE TO CARDIAC REHABILITATION
date
Diagnosis
Item
Diagnose
string
C0011900 (UMLS CUI)
439401001 (SNOMED CT 2010_0731)
MTHU008876 (LOINC Version 232)
Current Weight
Item
Gewicht
string
C1305866 (UMLS CUI)
107647005 (SNOMED CT 2010_0731)
10047890 (MedDRA 13.1)
LP18015-5 (LOINC Version 232)
Current Height
Item
Größe
string
C0489786 (UMLS CUI)
MTHU005354 (LOINC Version 232)
BMI
Item
BMI
string
C1305855 (UMLS CUI)
140075008 (SNOMED CT 2010_0731)
10005894 (MedDRA 13.1)
LP35925-4 (LOINC Version 232)
Item Group
C1457887 (UMLS CUI-1)
SYMPTOM(S) ON ADMISSION
Item
SYMPTOM(S) ON ADMISSION (Arm/Shoulder discomfort, Chest discomfort, Diaphoresis and sweating, Dizziness, Dyspnea/SOB, Fatigue, Indigestion, Nausea/Vomiting, Neck/Jaw discomfort, Other)
string
Item Group
C0559157 (UMLS CUI-1)
PAST CARDIAC HISTORY
Item
PAST CARDIAC HISTORY
text
C0559157 (UMLS CUI-1)
Item Group
C0262926 (UMLS CUI-1)
ARF/Dialysis
Item
Akutes Nierenversagen/Dialyse
string
Arthritis
Item
Arthritis
string
C0003864 (UMLS CUI)
3723001 (SNOMED CT 2010_0731)
10003246 (MedDRA 13.1)
MTHU020793 (LOINC Version 232)
M19.90 (ICD-10-CM Version 2010)
716.9 (ICD-9-CM Version 2011)
E12378 (CTCAE Version 4.03)
Asthma
Item
Asthma
string
C0004096 (UMLS CUI)
195967001 (SNOMED CT 2010_0731)
10003553 (MedDRA 13.1)
MTHU020815 (LOINC Version 232)
J45 (ICD-10-CM Version 2010)
493 (ICD-9-CM Version 2011)
Cancer
Item
Krebs
string
C0006826 (UMLS CUI)
363346000 (SNOMED CT 2010_0731)
10028997 (MedDRA 13.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)
COPD
Item
COPD
string
C0024117 (UMLS CUI)
13645005 (SNOMED CT 2010_0731)
10009033 (MedDRA 13.1)
J44.9 (ICD-10-CM Version 2010)
496 (ICD-9-CM Version 2011)
Depression
Item
Depression
string
C0011581 (UMLS CUI)
35489007 (SNOMED CT 2010_0731)
10012401 (MedDRA 13.1)
F32.9 (ICD-10-CM Version 2010)
Orthopedic Limitation
Item
Orthopedic Limitation
string
Thyroid Disorder
Item
Schilddrüsenerkrankung
string
C0040128 (UMLS CUI)
14304000 (SNOMED CT 2010_0731)
10043709 (MedDRA 13.1)
E00-E07 (ICD-10-CM Version 2010)
240-246.99 (ICD-9-CM Version 2011)
Other
Item
Other
string
History of Hypertension
Item
History of Hypertension
text
C0455527 (UMLS CUI-1)
History of Diabetes
Item
History of Diabetes
string
Cholesterol History
Item
Cholesterol History
string
LIPID VALUES THIS ADMISSION
Item
LIPID VALUES THIS ADMISSION
string
Physical Activity
Item
Körperliche Aktivität
string
C0026606 (UMLS CUI)
68130003 (SNOMED CT 2010_0731)
MTHU017278 (LOINC Version 232)
Family Status
Item
Family Status
text
C0682315 (UMLS CUI-1)
PATIENT LIVES
Item
PATIENT LIVES
string
Employment Status
Item
Beschäftigungsstatus
string
C0242271 (UMLS CUI)
224362002 (SNOMED CT 2010_0731)
Family History
Item
Familienanamnese
string
C0241889 (UMLS CUI)
57177007 (SNOMED CT 2010_0731)
Stress/ Psychological Concerns
Item
Stress
string
C0038435 (UMLS CUI)
262188008 (SNOMED CT 2010_0731)
10042209 (MedDRA 13.1)
PATIENT APPEARS (Behavior)
Item
PATIENT APPEARS (Behavior)
string
Uses tobacco products
Item
Raucher
text
C0543414 (UMLS CUI-1)
HOW MUCH Smoking
Item
HOW MUCH Smoking
text
C1822491 (UMLS CUI-1)
Quit at time of hospitalization
Item
Quit at time of hospitalization
string
Former smoker(not smoked more than 6 months)
Item
Former smoker(not smoked more than 6 months)
string
Quit smoking in
Item
Quit smoking in
date
Never Smoked
Item
Never Smoked
string
NARRATIVE
Item
NARRATIVE
string
CARDIAC CATHETERIZATION
Item
Herzkatheter
string
C0018795 (UMLS CUI)
41976001 (SNOMED CT 2010_0731)
10007815 (MedDRA 13.1)
37.21 (ICD-9-CM Version 2011)
CARDIAC CATHETERIZATION DATE
Item
CARDIAC CATHETERIZATION DATE
string
Ejection Fraction
Item
Ejektionsfraktion (EF)
string
C0232174 (UMLS CUI)
70822001 (SNOMED CT 2010_0731)
LV FUNCTION
Item
LV FUNCTION
string
MARK WITH % OCCLUSIONS
Item
MARK WITH % OCCLUSIONS
string
LM
Item
LM
string
LAD
Item
LAD
string
DIAGONAL
Item
DIAGONAL
string
CX
Item
CX
string
ADDITIONAL COMMENTS
Item
ADDITIONAL COMMENTS
string
PTCI / STENT
Item
PTCI / STENT
string
PTCI DATE
Item
PTCI DATE
string
PTCA
Item
PTCA
text
C2936173 (UMLS CUI-1)
STENT
Item
STENT
text
C0038257 (UMLS CUI-1)
ATHERECTOMY
Item
ATHERECTOMY
string
IIB/IIA INHIBITOR
Item
IIB/IIA INHIBITOR
string
MARK WITH APPROPRIATE LETTER: PTCA-(P), STENT-(S), ATHERECTOMY-(A)
Item
MARK WITH APPROPRIATE LETTER: PTCA-(P), STENT-(S), ATHERECTOMY-(A)
string
LM
Item
LM
string
LAD
Item
LAD
text
C0226032 (UMLS CUI-1)
DIAGONAL
Item
DIAGONAL
string
CX
Item
CX
string
ADDITIONAL COMMENTS
Item
ADDITIONAL COMMENTS
string
SURGERY
Item
SURGERY
string
CABG
Item
Koronare Bypassoperation
string
C0010055 (UMLS CUI)
232717009 (SNOMED CT 2010_0731)
10011077 (MedDRA 13.1)
36.10 (ICD-9-CM Version 2011)
DATE CABG
Item
DATE CABG
date
MIDCAB
Item
MIDCAB
string
AVR
Item
AVR
string
MVR
Item
MVR
string
OTHER PROCEDURES
Item
OTHER PROCEDURES
string
CARDIOVASCULAR RISK FACTOR
Item
CARDIOVASCULAR RISK FACTOR
string
CORRELATE A NUMBER WITH GRAFT ORIGIN SITE
Item
CORRELATE A NUMBER WITH GRAFT ORIGIN SITE
string
DONOR AREA TO
Item
DONOR AREA TO
string
LIMA
Item
LIMA
string
RIMA
Item
RIMA
string
RADIAL
Item
RADIAL
string
SVG
Item
SVG
string
RPD
Item
RPD
string
BOOKLET(S) GIVEN
Item
BOOKLET(S) GIVEN
string
DATE BOOKLET(S) given
Item
DATE BOOKLET(S) given
date
BOOKLET VERSIONS
Item
BOOKLET VERSIONS
string
VIDEO(S) SHOWN
Item
VIDEO(S) SHOWN
string
DATE VIDEO(S) shown
Item
DATE VIDEO(S) shown
string
VIDEO VERSION
Item
VIDEO VERSION
string
LEARNER
Item
LEARNER
string
PATIENT'S PHYSICAL READINESS TO LEARN
Item
PATIENT'S PHYSICAL READINESS TO LEARN
string
PSYCHOLOGICALLY WILLING TO LEARN
Item
PSYCHOLOGICALLY WILLING TO LEARN
string
EDUCATIONAL TOPICS Heart Disease
Item
EDUCATIONAL TOPICS: 1.Description of Cardiac Catheterization and site care, 2.Heart structure and function, 3.Myocardial Infarction symptoms and interventions, 4.Unstable Angina symptoms and interventons, 5.Congestive Heart Failure and importance of daily weights, 6.PTCI (Angioplasty,Stent), 7.Open Heart Surgery
string
EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION
Item
EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION: 1.Tobacco Cessation, 2.Exercise guidelines, aerobic exercise for minimum of 30 minutes, 3.Dietary Modifications, 4.Stress Management, 5.Cholesterol and Triglycerides, 6.Diabetes Management, 7.Obesity, 8.Medication, 9.Hypertension
string
DISCHARGE SPECIFIC INSTRUCTIONS
Item
DISCHARGE SPECIFIC INSTRUCTIONS: 1.Activity, 2.Site / Incision care, 3.Daily Weight, 4.Returning to work, 5.Driving, 6.Recurrent Chest Pain, 7.Psychosocial, 8.Coumadin, 9.Sex
string
CARDIAC REHAB NARRATIVE
Item
CARDIAC REHAB NARRATIVE
string

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video