ID

17410

Description

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Chirurgische Endoskopie (UKM) - Anforderung.

Keywords

Versions (3)
  1. 9/9/16 9/9/16 -
  2. 9/9/16 9/9/16 -
  3. 9/12/16 9/12/16 -
Uploaded on

September 12, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Surgical Endoscopy - Request University Hospital Muenster (UKM)

German

Surgical Endoscopy - Request University Hospital Muenster (UKM)

1 forms  
Administrative Daten
Description

Administrative Daten

Pat.:
Description

patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Fall-Nr.:
Description

case number

Data type

text

Alias
UMLS CUI [1,1]
C0872057
UMLS CUI [1,2]
C1300638
Geb.Dat.:
Description

birth date

Data type

date

Alias
UMLS CUI [1]
C0421451
Geschlecht
Description

sex

Data type

text

Alias
UMLS CUI [1]
C0150831
Pat.-ID:
Description

patient identifier

Data type

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0030705
PID:
Description

PID

Data type

text

Anforderung einer chirurgischen Endoskopie
Description

Anforderung einer chirurgischen Endoskopie

Alias
UMLS CUI-1
C0282493
UMLS CUI-2
C1272683
Dringlichkeit
Description

urgency

Data type

text

Alias
UMLS CUI [1,1]
C0282493
UMLS CUI [1,2]
C2188402
Auftragsnummer:
Description

ID of request

Data type

text

Alias
UMLS CUI [1,1]
C0282493
UMLS CUI [1,2]
C1272683
UMLS CUI [1,3]
C0600091
Auftragsdatum /-zeit:
Description

Date of request

Data type

datetime

Alias
UMLS CUI [1,1]
C0282493
UMLS CUI [1,2]
C1272683
UMLS CUI [1,3]
C0011008
Fachabteilung:
Description

hospital unit

Data type

text

Alias
UMLS CUI [1]
C0019988
Anfordernde Stelle:
Description

requesting unit

Data type

text

Alias
UMLS CUI [1,1]
C1272683
UMLS CUI [1,2]
C2981734
Leistende Stelle:
Description

providing unit

Data type

text

Alias
UMLS CUI [1,1]
C1272683
UMLS CUI [1,2]
C1138603
Gewünschte Leistungen
Description

Gewünschte Leistungen

Art der Anforderung
Description

requested test

Data type

text

Alias
UMLS CUI [1,1]
C0014245
UMLS CUI [1,2]
C0332307
UMLS CUI [1,3]
C1272683
Untersuchung
Description

requested test specification

Data type

text

Alias
UMLS CUI [1,1]
C0014245
UMLS CUI [1,2]
C1272683
Zusatzuntersuchung
Description

additional test

Data type

text

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C1524062
Maßnahmen
Description

actions

Data type

text

Alias
UMLS CUI [1]
C0441472
Terminwunsch
Description

scheduled date

Data type

datetime

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C2986272
Kommentar
Description

comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Weitere Daten
Description

Weitere Daten

Cave
Description

cave

Data type

text

Alias
UMLS CUI [1]
C0871599
Klinische Diagnose
Description

clinical diagnosis

Data type

text

Alias
UMLS CUI [1]
C0332140
Vorbefunde
Description

previous findings

Data type

text

Alias
UMLS CUI [1]
C0332132
Indikationen
Description

Indikationen

Alias
UMLS CUI-1
C2315323
Symptome
Description

symptoms

Data type

text

Alias
UMLS CUI [1]
C1457887
Erkrankungen Achalasie
Description

achalasia

Data type

boolean

Alias
UMLS CUI [1]
C1321756
Erkrankungen Bronchusstenose
Description

stenosis of bronchus

Data type

boolean

Alias
UMLS CUI [1]
C0151536
Erkrankungen CED
Description

IBD

Data type

boolean

Alias
UMLS CUI [1]
C0021390
Erkrankungen Diabetische Gastroparese
Description

gastroparesis due to diabetes mellitus

Data type

boolean

Alias
UMLS CUI [1]
C0267176
Erkrankungen Gastrointestinale Blutung
Description

gastrointestinal hemorrhage

Data type

boolean

Alias
UMLS CUI [1]
C0017181
Erkrankungen Klatskintumor mit Cholestase
Description

Klatskin tumor

Data type

boolean

Alias
UMLS CUI [1]
C0206702
Erkrankungen Pankreaskarzinom
Description

pancreatic carcinoma

Data type

boolean

Alias
UMLS CUI [1]
C0235974
Erkrankungen Peritonealkarzinose
Description

carcinomatosis of peritoneal cavity

Data type

boolean

Alias
UMLS CUI [1]
C0346990
Erkrankungen postoperative Gastroparese
Description

postoperative gastroparesis

Data type

boolean

Alias
UMLS CUI [1]
C0854519
Erkrankungen Magenentleerungsstörung
Description

stomach emptying disorder

Data type

boolean

Alias
UMLS CUI [1]
C0156084
Freitext-Indikation
Description

indication free text

Data type

text

Alias
UMLS CUI [1,1]
C2315323
UMLS CUI [1,2]
C2169878
Bes. Fragestellung
Description

formulation of question

Data type

text

Sonstiges
Description

Sonstiges

Infektiosität: Keine
Description

infectivity none

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0549184
Infektiosität: Nicht bekannt
Description

infectivity unknown

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0439673
Infektiosität: Hep. B
Description

infectivity hepatitis B

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0019163
Infektiosität: Hep. C
Description

infectivity hepatitis C

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0019196
Infektiosität: Tbc
Description

infectivity tuberculosis

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0041296
Infektiosität: HIV
Description

infectivity HIV

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0019682
Infektiosität: VRE
Description

infectivity vancomycin-resistant enterococci

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C1265175
Infektiosität: MRSA
Description

infectivity MRSA

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0343401
Infektiosität: Sonstiges
Description

infectivity other

Data type

boolean

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0205394
Infektiosität: Sonstiges
Description

infectivity other specify

Data type

text

Alias
UMLS CUI [1,1]
C0030657
UMLS CUI [1,2]
C0205394
Versichertenstatus - Privat
Description

health insurance group

Data type

boolean

Alias
UMLS CUI [1]
C0018256
Schwangerschaft liegt vor:
Description

pregnancy

Data type

text

Alias
UMLS CUI [1]
C0032961
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Similar models

Surgical Endoscopy - Request University Hospital Muenster (UKM)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Daten
patient name
Item
Pat.:
text
C1299487 (UMLS CUI [1])
case number
Item
Fall-Nr.:
text
C0872057 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
birth date
Item
Geb.Dat.:
date
C0421451 (UMLS CUI [1])
Item
Geschlecht
text
C0150831 (UMLS CUI [1])
sex
Code List
Geschlecht
CL Item
W (W)
CL Item
M (M)
patient identifier
Item
Pat.-ID:
text
C0600091 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
PID
Item
PID:
text
Item Group
Anforderung einer chirurgischen Endoskopie
C0282493 (UMLS CUI-1)
C1272683 (UMLS CUI-2)
Item
Dringlichkeit
text
C0282493 (UMLS CUI [1,1])
C2188402 (UMLS CUI [1,2])
urgency
Code List
Dringlichkeit
CL Item
normal (normal)
CL Item
dringend (dringend)
CL Item
Notfall (Notfall)
ID of request
Item
Auftragsnummer:
text
C0282493 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Date of request
Item
Auftragsdatum /-zeit:
datetime
C0282493 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
hospital unit
Item
Fachabteilung:
text
C0019988 (UMLS CUI [1])
requesting unit
Item
Anfordernde Stelle:
text
C1272683 (UMLS CUI [1,1])
C2981734 (UMLS CUI [1,2])
providing unit
Item
Leistende Stelle:
text
C1272683 (UMLS CUI [1,1])
C1138603 (UMLS CUI [1,2])
Item Group
Gewünschte Leistungen
Item
Art der Anforderung
text
C0014245 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C1272683 (UMLS CUI [1,3])
requested test
Code List
Art der Anforderung
CL Item
Transplantationsmed. Endoskopie (UKM) (Transplantationsmed. Endoskopie (UKM))
CL Item
Internistische Endoskopie (UKM) (Internistische Endoskopie (UKM))
CL Item
Chirurgische Endoskopie (UKM) (Chirurgische Endoskopie (UKM))
CL Item
Bronchoskopie Med-A (UKM) (Bronchoskopie Med-A (UKM))
CL Item
Pädiatrische Endoskopie (UKM) (Pädiatrische Endoskopie (UKM))
Item
Untersuchung
text
C0014245 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
requested test specification
Code List
Untersuchung
CL Item
Bronchoskopie (Bronchoskopie)
CL Item
ERCP (Endosk. retrogr. Cholangio- und Pankreatikographie) (ERCP (Endosk. retrogr. Cholangio- und Pankreatikographie))
CL Item
PTC (Perkutan- Transhepatische Cholangiographie) (PTC (Perkutan- Transhepatische Cholangiographie))
CL Item
PTCD (Perkutan- Transhepatische Cholangio-Drainage) (PTCD (Perkutan- Transhepatische Cholangio-Drainage))
CL Item
Hohe Coloskopie (Hohe Coloskopie)
CL Item
Totale Coloskopie (Totale Coloskopie)
CL Item
ÖGD (Oesophago-Gastro-Duodenoskopie) (ÖGD (Oesophago-Gastro-Duodenoskopie))
CL Item
Proktoskopie (Proktoskopie)
CL Item
Rektoskopie (Rektoskopie)
CL Item
Sigmoidoskopie (Sigmoidoskopie)
CL Item
Sonstiges (Sonstiges)
additional test
Item
Zusatzuntersuchung
text
C0430022 (UMLS CUI [1,1])
C1524062 (UMLS CUI [1,2])
actions
Item
Maßnahmen
text
C0441472 (UMLS CUI [1])
scheduled date
Item
Terminwunsch
datetime
C0430022 (UMLS CUI [1,1])
C2986272 (UMLS CUI [1,2])
comment
Item
Kommentar
text
C0947611 (UMLS CUI [1])
Item Group
Weitere Daten
cave
Item
Cave
text
C0871599 (UMLS CUI [1])
clinical diagnosis
Item
Klinische Diagnose
text
C0332140 (UMLS CUI [1])
previous findings
Item
Vorbefunde
text
C0332132 (UMLS CUI [1])
Item Group
Indikationen
C2315323 (UMLS CUI-1)
symptoms
Item
Symptome
text
C1457887 (UMLS CUI [1])
achalasia
Item
Erkrankungen Achalasie
boolean
C1321756 (UMLS CUI [1])
stenosis of bronchus
Item
Erkrankungen Bronchusstenose
boolean
C0151536 (UMLS CUI [1])
IBD
Item
Erkrankungen CED
boolean
C0021390 (UMLS CUI [1])
gastroparesis due to diabetes mellitus
Item
Erkrankungen Diabetische Gastroparese
boolean
C0267176 (UMLS CUI [1])
gastrointestinal hemorrhage
Item
Erkrankungen Gastrointestinale Blutung
boolean
C0017181 (UMLS CUI [1])
Klatskin tumor
Item
Erkrankungen Klatskintumor mit Cholestase
boolean
C0206702 (UMLS CUI [1])
pancreatic carcinoma
Item
Erkrankungen Pankreaskarzinom
boolean
C0235974 (UMLS CUI [1])
carcinomatosis of peritoneal cavity
Item
Erkrankungen Peritonealkarzinose
boolean
C0346990 (UMLS CUI [1])
postoperative gastroparesis
Item
Erkrankungen postoperative Gastroparese
boolean
C0854519 (UMLS CUI [1])
stomach emptying disorder
Item
Erkrankungen Magenentleerungsstörung
boolean
C0156084 (UMLS CUI [1])
indication free text
Item
Freitext-Indikation
text
C2315323 (UMLS CUI [1,1])
C2169878 (UMLS CUI [1,2])
formulation of question
Item
Bes. Fragestellung
text
Item Group
Sonstiges
infectivity none
Item
Infektiosität: Keine
boolean
C0030657 (UMLS CUI [1,1])
C0549184 (UMLS CUI [1,2])
infectivity unknown
Item
Infektiosität: Nicht bekannt
boolean
C0030657 (UMLS CUI [1,1])
C0439673 (UMLS CUI [1,2])
infectivity hepatitis B
Item
Infektiosität: Hep. B
boolean
C0030657 (UMLS CUI [1,1])
C0019163 (UMLS CUI [1,2])
infectivity hepatitis C
Item
Infektiosität: Hep. C
boolean
C0030657 (UMLS CUI [1,1])
C0019196 (UMLS CUI [1,2])
infectivity tuberculosis
Item
Infektiosität: Tbc
boolean
C0030657 (UMLS CUI [1,1])
C0041296 (UMLS CUI [1,2])
infectivity HIV
Item
Infektiosität: HIV
boolean
C0030657 (UMLS CUI [1,1])
C0019682 (UMLS CUI [1,2])
infectivity vancomycin-resistant enterococci
Item
Infektiosität: VRE
boolean
C0030657 (UMLS CUI [1,1])
C1265175 (UMLS CUI [1,2])
infectivity MRSA
Item
Infektiosität: MRSA
boolean
C0030657 (UMLS CUI [1,1])
C0343401 (UMLS CUI [1,2])
infectivity other
Item
Infektiosität: Sonstiges
boolean
C0030657 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
infectivity other specify
Item
Infektiosität: Sonstiges
text
C0030657 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
health insurance group
Item
Versichertenstatus - Privat
boolean
C0018256 (UMLS CUI [1])
Item
Schwangerschaft liegt vor:
text
C0032961 (UMLS CUI [1])
pregnancy
Code List
Schwangerschaft liegt vor:
CL Item
nein (nein)
CL Item
ja, Rücksprache mit OA (ja, Rücksprache mit OA)
CL Item
nicht bekannt (nicht bekannt)
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