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ID

14884

Beschreibung

Item used as routine documentation by Clinic Erlangen, Dermatology, Outpatient Department. ODM derived from original form “Derma- Ambulanz Erlangen”.

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Versionen (1)
  1. 03.05.16 03.05.16 -
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3. Mai 2016

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Creative Commons BY-NC 3.0
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    Outpatient Department Form Dermatology Clinic Erlangen

    Englisch

    Outpatient Department Form Dermatology

    1 Formulare  
    Principal diagnosis
    Beschreibung

    Principal diagnosis

    Alias
    UMLS CUI-1
    C0332137
    Principal diagnosis 1
    Beschreibung

    principal diagnosis

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0332137
    Diagnosis unchanged since
    Beschreibung

    date diagnosis

    Datentyp

    date

    Alias
    UMLS CUI [1]
    C2316983
    Principal diagnosis 2
    Beschreibung

    Principal diagnosis

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0332137
    Diagnosis unchanged since
    Beschreibung

    date diagnosis

    Datentyp

    date

    Alias
    UMLS CUI [1]
    C2316983
    Attending physician today
    Beschreibung

    attending physician

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C2361125
    Today's visit without appointment?
    Beschreibung

    Appointment

    Datentyp

    boolean

    Alias
    UMLS CUI [1]
    C0586344
    Important note (e.g. Infection)
    Beschreibung

    important note

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C1317574
    Patient's occupation
    Beschreibung

    Patient occupation

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0421456
    Medical History
    Beschreibung

    Medical History

    Alias
    UMLS CUI-1
    C0262926
    Previous diseases
    Beschreibung

    Previous diseases

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0262926
    Diagnosis unchanged
    Beschreibung

    date diagnosis

    Datentyp

    date

    Alias
    UMLS CUI [1]
    C2316983
    Long- term medication
    Beschreibung

    long term medication

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C2054144
    Medication unchanged since
    Beschreibung

    date Medication commenced

    Datentyp

    date

    Alias
    UMLS CUI [1,1]
    C0011008
    UMLS CUI [1,2]
    C0451613
    Allergies
    Beschreibung

    Hypersensitivity

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0020517
    Allergy unchanged since
    Beschreibung

    date hypersensitivity

    Datentyp

    date

    Alias
    UMLS CUI [1,1]
    C0011008
    UMLS CUI [1,2]
    C0020517
    Medical history of family
    Beschreibung

    Family medical history

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0241889
    Family history unchanged since
    Beschreibung

    date family history

    Datentyp

    date

    Alias
    UMLS CUI [1,1]
    C0011008
    UMLS CUI [1,2]
    C0241889
    Current average alcohol consumption
    Beschreibung

    alcohol consumption

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0001948
    Current nicotine consumption
    Beschreibung

    nicotine consumption

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C1519386
    Medical history
    Beschreibung

    medical history

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0262926
    Medical Examination
    Beschreibung

    Medical Examination

    Alias
    UMLS CUI-1
    C0582103
    Physical examination carried out today?
    Beschreibung

    Physical examination

    Datentyp

    boolean

    Alias
    UMLS CUI [1]
    C0031809
    Physical examination
    Beschreibung

    Physical examination

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0031809
    Date of last physical examination
    Beschreibung

    date Physical examination

    Datentyp

    date

    Alias
    UMLS CUI [1,1]
    C0011008
    UMLS CUI [1,2]
    C0031809
    Dermatological Diagnosis
    Beschreibung

    Dermatological Diagnosis

    Alias
    UMLS CUI-1
    C0011900
    UMLS CUI-2
    C0011627
    Principal diagnosis 1
    Beschreibung

    Location: Lips .0, Eye .1, Ear .2, Face .3, Scalp and neck .4, Trunk .5, Arm/ shoulder .6, Leg/ Hip .7, Several overlapping .8, Tumors (location independent) .9 Please fill in the diagnostics (A, V, G, Z, R, L, B) according to the ICD codes

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0332137
    Date of diagnosis
    Beschreibung

    date diagnosis

    Datentyp

    date

    Alias
    UMLS CUI [1]
    C2316983
    Principal diagnosis 2
    Beschreibung

    Location: Lips .0, Eye .1, Ear .2, Face .3, Scalp and neck .4, Trunk .5, Arm/ shoulder .6, Leg/ Hip .7, Several overlapping .8, Tumors (location independent) .9 Please fill in the diagnostics (A, V, G, Z, R, L, B) according to the ICD codes

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0332137
    Date of diagnosis
    Beschreibung

    date diagnosis

    Datentyp

    date

    Alias
    UMLS CUI [1]
    C2316983
    Procedure
    Beschreibung

    Procedure

    Alias
    UMLS CUI-1
    C0184661
    Procedure
    Beschreibung

    Procedure

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0184661
    Senior physician
    Beschreibung

    Senior physician

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0031831
    Follow- up in (days/ weeks/ months)
    Beschreibung

    Follow- up

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C1522577
    Follow- up
    Beschreibung

    Follow- up

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C1522577
    Nursing measures and procedures
    Beschreibung

    Nursing procedure

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0204636
    Photograph instructed today?
    Beschreibung

    Photo

    Datentyp

    boolean

    Alias
    UMLS CUI [1]
    C0441468
    Last photo taken on
    Beschreibung

    date photo

    Datentyp

    date

    Alias
    UMLS CUI [1,1]
    C0011008
    UMLS CUI [1,2]
    C0441468
    Other
    Beschreibung

    Other

    Alias
    UMLS CUI-1
    C0205394
    Study participation status
    Beschreibung

    study participation status

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C2348568
    Studies
    Beschreibung

    Clinical trials

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0008976
    Memo (For letters and outdoor patient list e.g. addressees, etc.)
    Beschreibung

    Memo

    Datentyp

    text

    Internal Notes
    Beschreibung

    Notes

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0947611
    Nursing notes
    Beschreibung

    Nursing notes

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C1718140
    Zum Seitenanfang zurückkehren

    Ähnliche Modelle

    Outpatient Department Form Dermatology

    1 Formulare
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Principal diagnosis
    C0332137 (UMLS CUI-1)
    principal diagnosis
    Item
    Principal diagnosis 1
    text
    C0332137 (UMLS CUI [1])
    date diagnosis
    Item
    Diagnosis unchanged since
    date
    C2316983 (UMLS CUI [1])
    Principal diagnosis
    Item
    Principal diagnosis 2
    text
    C0332137 (UMLS CUI [1])
    date diagnosis
    Item
    Diagnosis unchanged since
    date
    C2316983 (UMLS CUI [1])
    attending physician
    Item
    Attending physician today
    text
    C2361125 (UMLS CUI [1])
    Appointment
    Item
    Today's visit without appointment?
    boolean
    C0586344 (UMLS CUI [1])
    important note
    Item
    Important note (e.g. Infection)
    text
    C1317574 (UMLS CUI [1])
    Patient occupation
    Item
    Patient's occupation
    text
    C0421456 (UMLS CUI [1])
    Item Group
    Medical History
    C0262926 (UMLS CUI-1)
    Previous diseases
    Item
    Previous diseases
    text
    C0262926 (UMLS CUI [1])
    date diagnosis
    Item
    Diagnosis unchanged
    date
    C2316983 (UMLS CUI [1])
    long term medication
    Item
    Long- term medication
    text
    C2054144 (UMLS CUI [1])
    date Medication commenced
    Item
    Medication unchanged since
    date
    C0011008 (UMLS CUI [1,1])
    C0451613 (UMLS CUI [1,2])
    Hypersensitivity
    Item
    Allergies
    text
    C0020517 (UMLS CUI [1])
    date hypersensitivity
    Item
    Allergy unchanged since
    date
    C0011008 (UMLS CUI [1,1])
    C0020517 (UMLS CUI [1,2])
    Family medical history
    Item
    Medical history of family
    text
    C0241889 (UMLS CUI [1])
    date family history
    Item
    Family history unchanged since
    date
    C0011008 (UMLS CUI [1,1])
    C0241889 (UMLS CUI [1,2])
    alcohol consumption
    Item
    Current average alcohol consumption
    text
    C0001948 (UMLS CUI [1])
    nicotine consumption
    Item
    Current nicotine consumption
    text
    C1519386 (UMLS CUI [1])
    medical history
    Item
    Medical history
    text
    C0262926 (UMLS CUI [1])
    Item Group
    Medical Examination
    C0582103 (UMLS CUI-1)
    Physical examination
    Item
    Physical examination carried out today?
    boolean
    C0031809 (UMLS CUI [1])
    Physical examination
    Item
    Physical examination
    text
    C0031809 (UMLS CUI [1])
    date Physical examination
    Item
    Date of last physical examination
    date
    C0011008 (UMLS CUI [1,1])
    C0031809 (UMLS CUI [1,2])
    Item Group
    Dermatological Diagnosis
    C0011900 (UMLS CUI-1)
    C0011627 (UMLS CUI-2)
    Principal diagnosis
    Item
    Principal diagnosis 1
    text
    C0332137 (UMLS CUI [1])
    date diagnosis
    Item
    Date of diagnosis
    date
    C2316983 (UMLS CUI [1])
    Principal diagnosis
    Item
    Principal diagnosis 2
    text
    C0332137 (UMLS CUI [1])
    date diagnosis
    Item
    Date of diagnosis
    date
    C2316983 (UMLS CUI [1])
    Item Group
    Procedure
    C0184661 (UMLS CUI-1)
    Procedure
    Item
    Procedure
    text
    C0184661 (UMLS CUI [1])
    Senior physician
    Item
    Senior physician
    text
    C0031831 (UMLS CUI [1])
    Follow- up
    Item
    Follow- up in (days/ weeks/ months)
    text
    C1522577 (UMLS CUI [1])
    Item
    Follow- up
    text
    C1522577 (UMLS CUI [1])
    Follow- up
    Code List
    Follow- up
    CL Item
    as required (1)
    CL Item
    by GP (2)
    Nursing procedure
    Item
    Nursing measures and procedures
    text
    C0204636 (UMLS CUI [1])
    Photo
    Item
    Photograph instructed today?
    boolean
    C0441468 (UMLS CUI [1])
    date photo
    Item
    Last photo taken on
    date
    C0011008 (UMLS CUI [1,1])
    C0441468 (UMLS CUI [1,2])
    Item Group
    Other
    C0205394 (UMLS CUI-1)
    Item
    Study participation status
    text
    C2348568 (UMLS CUI [1])
    study participation status
    Code List
    Study participation status
    CL Item
    previous study participation of the patient (1)
    CL Item
    current consultation is part of a study (2)
    Clinical trials
    Item
    Studies
    text
    C0008976 (UMLS CUI [1])
    Memo
    Item
    Memo (For letters and outdoor patient list e.g. addressees, etc.)
    text
    Notes
    Item
    Internal Notes
    text
    C0947611 (UMLS CUI [1])
    Nursing notes
    Item
    Nursing notes
    text
    C1718140 (UMLS CUI [1])
    Zum Seitenanfang zurückkehren 

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