ID

11976

Description

Form from HIS OpenVistA

Keywords

  1. 2/10/12 2/10/12 -
  2. 7/9/15 7/9/15 - Martin Dugas
  3. 8/28/15 8/28/15 - Martin Dugas
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August 28, 2015

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License

Creative Commons BY-NC 3.0 Legacy

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    CARDIAC REHAB CONSULT RESULTS INTERDISCIPLINARY NOTE

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

    Date, Diagnosis, BMI

    DATE REFERRAL RECEIVED
    Description

    DATE REFERRAL RECEIVED

    Data type

    date

    ADMISSION DATE TO CARDIAC REHABILITATION
    Description

    ADMISSION DATE TO CARDIAC REHABILITATION

    Data type

    date

    Diagnosis
    Description

    Diagnosis

    Data type

    string

    Alias
    UMLS CUI
    C0011900
    SNOMED CT 2010_0731
    439401001
    LOINC Version 232
    MTHU008876
    Weight
    Description

    Current Weight

    Data type

    text

    Measurement units
    • kg
    Alias
    SNOMED CT 2010_0731
    107647005
    MedDRA 13.1
    10047890
    LOINC Version 232
    LP18015-5
    UMLS CUI [1]
    C0005910
    kg
    Height
    Description

    Current Height

    Data type

    float

    Measurement units
    • cm
    Alias
    LOINC Version 232
    MTHU005354
    UMLS CUI [1]
    C0489786
    cm
    Body Mass Index
    Description

    BMI

    Data type

    float

    Measurement units
    • kg/m2
    Alias
    SNOMED CT 2010_0731
    140075008
    MedDRA 13.1
    10005894
    LOINC Version 232
    LP35925-4
    UMLS CUI [1]
    C1305855
    kg/m2
    SYMPTOM(S) ON ADMISSION
    Description

    SYMPTOM(S) ON ADMISSION

    Alias
    UMLS CUI-1
    C1457887
    SYMPTOM(S) ON ADMISSION
    Description

    SYMPTOM(S) ON ADMISSION (Arm/Shoulder discomfort, Chest discomfort, Diaphoresis and sweating, Dizziness, Dyspnea/SOB, Fatigue, Indigestion, Nausea/Vomiting, Neck/Jaw discomfort, Other)

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1457887
    UMLS CUI [1,2]
    C0457453
    PAST CARDIAC HISTORY
    Description

    PAST CARDIAC HISTORY

    Alias
    UMLS CUI-1
    C0559157
    PAST CARDIAC HISTORY
    Description

    PAST CARDIAC HISTORY

    Data type

    text

    Alias
    UMLS CUI [1]
    C0559157
    PAST Medical HISTORY
    Description

    PAST Medical HISTORY

    Alias
    UMLS CUI-1
    C0262926
    Acute Renal Failure/Dialysis
    Description

    ARF/Dialysis

    Data type

    string

    Arthritis
    Description

    Arthritis

    Data type

    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
    Description

    Asthma

    Data type

    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
    Malignant Neoplasms
    Description

    Cancer

    Data type

    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
    Chronic Obstructive Pulmonary Disease
    Description

    COPD

    Data type

    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
    Description

    Depression

    Data type

    string

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

    Orthopedic Limitation

    Data type

    string

    Thyroid Disease
    Description

    Thyroid Disorder

    Data type

    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
    Description

    Other

    Data type

    string

    History of Hypertension
    Description

    History of Hypertension

    Data type

    text

    Alias
    UMLS CUI [1]
    C0455527
    History of Diabetes
    Description

    History of Diabetes

    Data type

    string

    Cholesterol History
    Description

    Cholesterol History

    Data type

    string

    LIPID VALUES THIS ADMISSION
    Description

    LIPID VALUES THIS ADMISSION

    Data type

    string

    Physical activity
    Description

    Physical Activity

    Data type

    string

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

    PERTINENT SOCIAL HISTORY

    Family Status
    Description

    Family Status

    Data type

    text

    Alias
    UMLS CUI-1
    C0682315
    PATIENT LIVES
    Description

    PATIENT LIVES

    Data type

    string

    Employment status
    Description

    Employment Status

    Data type

    string

    Alias
    UMLS CUI
    C0242271
    SNOMED CT 2010_0731
    224362002
    Family history (FH) of
    Description

    Family History

    Data type

    string

    Alias
    UMLS CUI
    C0241889
    SNOMED CT 2010_0731
    57177007
    Stress
    Description

    Stress/ Psychological Concerns

    Data type

    string

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

    PATIENT APPEARS (Behavior)

    Data type

    string

    Smoking History
    Description

    Smoking History

    Alias
    UMLS CUI-1
    C1519384
    Smoker
    Description

    Smoker

    Data type

    text

    Alias
    UMLS CUI-1
    C0543414
    HOW MUCH Smoking
    Description

    HOW MUCH Smoking

    Data type

    text

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

    Quit at time of hospitalization

    Data type

    string

    Former smoker(not smoked more than 6 months)
    Description

    Former smoker(not smoked more than 6 months)

    Data type

    string

    Quit smoking in
    Description

    Quit smoking in

    Data type

    date

    Never Smoked
    Description

    Never Smoked

    Data type

    string

    NARRATIVE
    Description

    NARRATIVE

    Data type

    string

    Procedure Date and Results
    Description

    Procedure Date and Results

    Heart catheterization
    Description

    CARDIAC CATHETERIZATION

    Data type

    string

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

    CARDIAC CATHETERIZATION DATE

    Data type

    string

    Cardiac ejection fraction
    Description

    Ejection Fraction

    Data type

    string

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

    LV FUNCTION

    Data type

    string

    MARK WITH % OCCLUSIONS
    Description

    MARK WITH % OCCLUSIONS

    Data type

    string

    LM
    Description

    LM

    Data type

    string

    LAD
    Description

    LAD

    Data type

    string

    DIAGONAL
    Description

    DIAGONAL

    Data type

    string

    CX
    Description

    CX

    Data type

    string

    ADDITIONAL COMMENTS
    Description

    ADDITIONAL COMMENTS

    Data type

    string

    PTCI / STENT
    Description

    PTCI / STENT

    Data type

    string

    PTCI DATE
    Description

    PTCI DATE

    Data type

    string

    PTCA
    Description

    PTCA

    Data type

    text

    Alias
    UMLS CUI-1
    C2936173
    STENT
    Description

    STENT

    Data type

    text

    Alias
    UMLS CUI-1
    C0038257
    ATHERECTOMY
    Description

    ATHERECTOMY

    Data type

    string

    IIB/IIA INHIBITOR
    Description

    IIB/IIA INHIBITOR

    Data type

    string

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

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

    Data type

    string

    LM
    Description

    LM

    Data type

    string

    LAD
    Description

    LAD

    Data type

    text

    Alias
    UMLS CUI-1
    C0226032
    DIAGONAL
    Description

    DIAGONAL

    Data type

    string

    CX
    Description

    CX

    Data type

    string

    ADDITIONAL COMMENTS
    Description

    ADDITIONAL COMMENTS

    Data type

    string

    SURGERY
    Description

    SURGERY

    Data type

    string

    Coronary Artery Bypass Surgery
    Description

    CABG

    Data type

    string

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

    DATE CABG

    Data type

    date

    MIDCAB
    Description

    MIDCAB

    Data type

    string

    AVR
    Description

    AVR

    Data type

    string

    MVR
    Description

    MVR

    Data type

    string

    OTHER PROCEDURES
    Description

    OTHER PROCEDURES

    Data type

    string

    CARDIOVASCULAR RISK FACTOR
    Description

    CARDIOVASCULAR RISK FACTOR

    Data type

    string

    CORRELATE A NUMBER WITH GRAFT ORIGIN SITE
    Description

    CORRELATE A NUMBER WITH GRAFT ORIGIN SITE

    Data type

    string

    DONOR AREA TO
    Description

    DONOR AREA TO

    Data type

    string

    LIMA
    Description

    LIMA

    Data type

    string

    RIMA
    Description

    RIMA

    Data type

    string

    RADIAL
    Description

    RADIAL

    Data type

    string

    SVG
    Description

    SVG

    Data type

    string

    RPD
    Description

    RPD

    Data type

    string

    PATIENT/FAMILY EDUCATION
    Description

    PATIENT/FAMILY EDUCATION

    BOOKLET(S) GIVEN
    Description

    BOOKLET(S) GIVEN

    Data type

    string

    DATE BOOKLET(S) given
    Description

    DATE BOOKLET(S) given

    Data type

    date

    BOOKLET VERSIONS
    Description

    BOOKLET VERSIONS

    Data type

    string

    VIDEO(S) SHOWN
    Description

    VIDEO(S) SHOWN

    Data type

    string

    DATE VIDEO(S) shown
    Description

    DATE VIDEO(S) shown

    Data type

    string

    VIDEO VERSION
    Description

    VIDEO VERSION

    Data type

    string

    LEARNER
    Description

    LEARNER

    Data type

    string

    PATIENT'S PHYSICAL READINESS TO LEARN
    Description

    PATIENT'S PHYSICAL READINESS TO LEARN

    Data type

    string

    PSYCHOLOGICALLY WILLING TO LEARN
    Description

    PSYCHOLOGICALLY WILLING TO LEARN

    Data type

    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
    Description

    EDUCATIONAL TOPICS Heart Disease

    Data type

    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
    Description

    EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION

    Data type

    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
    Description

    DISCHARGE SPECIFIC INSTRUCTIONS

    Data type

    string

    CARDIAC REHAB NARRATIVE
    Description

    CARDIAC REHAB NARRATIVE

    Data type

    string

    Similar models

    1. StudyEvent: HIS
      1. HIS
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Date, Diagnosis, BMI
    DATE REFERRAL RECEIVED
    Item
    DATE REFERRAL RECEIVED
    date
    ADMISSION DATE TO CARDIAC REHABILITATION
    Item
    ADMISSION DATE TO CARDIAC REHABILITATION
    date
    Diagnosis
    Item
    Diagnosis
    string
    C0011900 (UMLS CUI)
    439401001 (SNOMED CT 2010_0731)
    MTHU008876 (LOINC Version 232)
    Current Weight
    Item
    Weight
    text
    107647005 (SNOMED CT 2010_0731)
    10047890 (MedDRA 13.1)
    LP18015-5 (LOINC Version 232)
    C0005910 (UMLS CUI [1])
    Current Height
    Item
    Height
    float
    MTHU005354 (LOINC Version 232)
    C0489786 (UMLS CUI [1])
    BMI
    Item
    Body Mass Index
    float
    140075008 (SNOMED CT 2010_0731)
    10005894 (MedDRA 13.1)
    LP35925-4 (LOINC Version 232)
    C1305855 (UMLS CUI [1])
    Item Group
    SYMPTOM(S) ON ADMISSION
    C1457887 (UMLS CUI-1)
    SYMPTOMS ON ADMISSION
    Item
    SYMPTOM(S) ON ADMISSION
    text
    C1457887 (UMLS CUI [1,1])
    C0457453 (UMLS CUI [1,2])
    Item Group
    PAST CARDIAC HISTORY
    C0559157 (UMLS CUI-1)
    PAST CARDIAC HISTORY
    Item
    PAST CARDIAC HISTORY
    text
    C0559157 (UMLS CUI [1])
    Item Group
    PAST Medical HISTORY
    C0262926 (UMLS CUI-1)
    ARF/Dialysis
    Item
    Acute Renal Failure/Dialysis
    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
    Malignant Neoplasms
    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
    Chronic Obstructive Pulmonary Disease
    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
    Thyroid Disease
    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
    Physical activity
    string
    C0026606 (UMLS CUI)
    68130003 (SNOMED CT 2010_0731)
    MTHU017278 (LOINC Version 232)
    Item Group
    PERTINENT SOCIAL HISTORY
    Family Status
    Item
    Family Status
    text
    C0682315 (UMLS CUI-1)
    PATIENT LIVES
    Item
    PATIENT LIVES
    string
    Employment Status
    Item
    Employment status
    string
    C0242271 (UMLS CUI)
    224362002 (SNOMED CT 2010_0731)
    Family History
    Item
    Family history (FH) of
    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
    Item Group
    Smoking History
    C1519384 (UMLS CUI-1)
    Uses tobacco products
    Item
    Smoker
    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
    Item Group
    Procedure Date and Results
    CARDIAC CATHETERIZATION
    Item
    Heart catheterization
    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
    Cardiac ejection fraction
    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
    Coronary Artery Bypass Surgery
    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
    Item Group
    PATIENT/FAMILY EDUCATION
    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

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