0 Ratings

ID

14884

Description

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

Keywords

  1. 5/3/16 5/3/16 -
Uploaded on

May 3, 2016

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :


    No comments

    In order to download data models you must be logged in. Please log in or register for free.

    Outpatient Department Form Dermatology Clinic Erlangen

    Outpatient Department Form Dermatology

    Principal diagnosis
    Description

    Principal diagnosis

    Alias
    UMLS CUI-1
    C0332137 (Principal diagnosis)
    SNOMED
    8319008
    LOINC
    MTHU008289
    Principal diagnosis 1
    Description

    principal diagnosis

    Data type

    text

    Alias
    UMLS CUI [1]
    C0332137 (Principal diagnosis)
    SNOMED
    8319008
    LOINC
    MTHU008289
    Diagnosis unchanged since
    Description

    date diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C2316983 (Date of diagnosis)
    SNOMED
    432213005
    LOINC
    LP114957-6
    Principal diagnosis 2
    Description

    Principal diagnosis

    Data type

    text

    Alias
    UMLS CUI [1]
    C0332137 (Principal diagnosis)
    SNOMED
    8319008
    LOINC
    MTHU008289
    Diagnosis unchanged since
    Description

    date diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C2316983 (Date of diagnosis)
    SNOMED
    432213005
    LOINC
    LP114957-6
    Attending physician today
    Description

    attending physician

    Data type

    text

    Alias
    UMLS CUI [1]
    C2361125 (Attending physician name)
    LOINC
    MTHU028124
    Today's visit without appointment?
    Description

    Appointment

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0586344 (Appointment status)
    SNOMED
    308817005
    Important note (e.g. Infection)
    Description

    important note

    Data type

    text

    Alias
    UMLS CUI [1]
    C1317574 (Note (document))
    LOINC
    LP72988-6
    Patient's occupation
    Description

    Patient occupation

    Data type

    text

    Alias
    UMLS CUI [1]
    C0421456 (Patient occupation)
    SNOMED
    184104002
    Medical History
    Description

    Medical History

    Alias
    UMLS CUI-1
    C0262926 (Medical History)
    SNOMED
    392521001
    LOINC
    LP6817-3
    Previous diseases
    Description

    Previous diseases

    Data type

    text

    Alias
    UMLS CUI [1]
    C0262926 (Medical History)
    SNOMED
    392521001
    LOINC
    LP6817-3
    Diagnosis unchanged
    Description

    date diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C2316983 (Date of diagnosis)
    SNOMED
    432213005
    LOINC
    LP114957-6
    Long- term medication
    Description

    long term medication

    Data type

    text

    Alias
    UMLS CUI [1]
    C2054144 (taking medication for a long time)
    Medication unchanged since
    Description

    date Medication commenced

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0011008 (Date in time)
    SNOMED
    410671006
    UMLS CUI [1,2]
    C0451613 (Medication commenced)
    SNOMED
    266709005
    Allergies
    Description

    Hypersensitivity

    Data type

    text

    Alias
    UMLS CUI [1]
    C0020517 (Hypersensitivity)
    SNOMED
    421961002
    LOINC
    LP20697-6
    Allergy unchanged since
    Description

    date hypersensitivity

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0011008 (Date in time)
    SNOMED
    410671006
    UMLS CUI [1,2]
    C0020517 (Hypersensitivity)
    SNOMED
    421961002
    LOINC
    LP20697-6
    Medical history of family
    Description

    Family medical history

    Data type

    text

    Alias
    UMLS CUI [1]
    C0241889 (Family history (finding))
    SNOMED
    416471007
    Family history unchanged since
    Description

    date family history

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0011008 (Date in time)
    SNOMED
    410671006
    UMLS CUI [1,2]
    C0241889 (Family history (finding))
    SNOMED
    416471007
    Current average alcohol consumption
    Description

    alcohol consumption

    Data type

    text

    Alias
    UMLS CUI [1]
    C0001948 (Alcohol consumption)
    SNOMED
    897148007
    LOINC
    MTHU047472
    Current nicotine consumption
    Description

    nicotine consumption

    Data type

    text

    Alias
    UMLS CUI [1]
    C1519386 (Smoking Status)
    Medical history
    Description

    medical history

    Data type

    text

    Alias
    UMLS CUI [1]
    C0262926 (Medical History)
    SNOMED
    392521001
    LOINC
    LP6817-3
    Medical Examination
    Description

    Medical Examination

    Alias
    UMLS CUI-1
    C0582103 (Medical Examination)
    SNOMED
    225886003
    Physical examination carried out today?
    Description

    Physical examination

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0031809 (Physical Examination)
    SNOMED
    5880005
    LOINC
    MTHU028014
    Physical examination
    Description

    Physical examination

    Data type

    text

    Alias
    UMLS CUI [1]
    C0031809 (Physical Examination)
    SNOMED
    5880005
    LOINC
    MTHU028014
    Date of last physical examination
    Description

    date Physical examination

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0011008 (Date in time)
    SNOMED
    410671006
    UMLS CUI [1,2]
    C0031809 (Physical Examination)
    SNOMED
    5880005
    LOINC
    MTHU028014
    Dermatological Diagnosis
    Description

    Dermatological Diagnosis

    Alias
    UMLS CUI-1
    C0011900 (Diagnosis)
    SNOMED
    439401001
    LOINC
    LP30831-9
    UMLS CUI-2
    C0011627 (Dermatology field)
    SNOMED
    394582007
    LOINC
    LP32891-1
    Principal diagnosis 1
    Description

    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

    Data type

    text

    Alias
    UMLS CUI [1]
    C0332137 (Principal diagnosis)
    SNOMED
    8319008
    LOINC
    MTHU008289
    Date of diagnosis
    Description

    date diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C2316983 (Date of diagnosis)
    SNOMED
    432213005
    LOINC
    LP114957-6
    Principal diagnosis 2
    Description

    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

    Data type

    text

    Alias
    UMLS CUI [1]
    C0332137 (Principal diagnosis)
    SNOMED
    8319008
    LOINC
    MTHU008289
    Date of diagnosis
    Description

    date diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C2316983 (Date of diagnosis)
    SNOMED
    432213005
    LOINC
    LP114957-6
    Procedure
    Description

    Procedure

    Alias
    UMLS CUI-1
    C0184661 (Interventional procedure)
    SNOMED
    71388002
    Procedure
    Description

    Procedure

    Data type

    text

    Alias
    UMLS CUI [1]
    C0184661 (Interventional procedure)
    SNOMED
    71388002
    Senior physician
    Description

    Senior physician

    Data type

    text

    Alias
    UMLS CUI [1]
    C0031831 (Physicians)
    SNOMED
    158965000
    LOINC
    LA18968-0
    Follow- up in (days/ weeks/ months)
    Description

    Follow- up

    Data type

    text

    Alias
    UMLS CUI [1]
    C1522577 (follow-up)
    Follow- up
    Description

    Follow- up

    Data type

    text

    Alias
    UMLS CUI [1]
    C1522577 (follow-up)
    Nursing measures and procedures
    Description

    Nursing procedure

    Data type

    text

    Alias
    UMLS CUI [1]
    C0204636 (Nursing procedure)
    SNOMED
    9632001
    Photograph instructed today?
    Description

    Photo

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0441468 (photograph)
    SNOMED
    257444003
    Last photo taken on
    Description

    date photo

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0011008 (Date in time)
    SNOMED
    410671006
    UMLS CUI [1,2]
    C0441468 (photograph)
    SNOMED
    257444003
    Other
    Description

    Other

    Alias
    UMLS CUI-1
    C0205394 (Other)
    SNOMED
    74964007
    LOINC
    LP21049-9
    Study participation status
    Description

    study participation status

    Data type

    text

    Alias
    UMLS CUI [1]
    C2348568 (Study Subject Participation Status)
    Studies
    Description

    Clinical trials

    Data type

    text

    Alias
    UMLS CUI [1]
    C0008976 (Clinical Trials)
    SNOMED
    110465008
    LOINC
    LP231796-6
    Memo (For letters and outdoor patient list e.g. addressees, etc.)
    Description

    Memo

    Data type

    text

    Internal Notes
    Description

    Notes

    Data type

    text

    Alias
    UMLS CUI [1]
    C0947611 (Comment)
    LOINC
    LP72293-1
    Nursing notes
    Description

    Nursing notes

    Data type

    text

    Alias
    UMLS CUI [1]
    C1718140 (Nursing notes)
    LOINC
    LP74183-2

    Similar models

    Outpatient Department Form Dermatology

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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])
    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])
    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])

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial