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ID
18256
Description
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Pädiatrische Anamnese
Keywords
Versions (2)
- 10/27/16 10/27/16 -
- 9/20/21 9/20/21 -
Uploaded on
October 27, 2016
DOI
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License
Creative Commons BY-NC 3.0
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Pediatric medical history MS University Hospital Muenster (UKM) Subform
Pädiatrische Anamnese MS University Hospital Muenster (UKM) Subform
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Pädiatrische Anamnese MS University Hospital Muenster (UKM) Subform
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
CL Item
stationäre Aufnahme (1)
CL Item
ambulante Vorstellung (2)
Medical history taken by
Item
Erhoben von
text
C0025084 (UMLS CUI [1,1])
C0680379 (UMLS CUI [1,2])
C0680379 (UMLS CUI [1,2])
Date medical history taken
Item
Erhoben am
date
C0025084 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Item
Erhebungsmodus
integer
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,2])
CL Item
Eigenanamnese (1)
CL Item
Fremdanamnese (2)
CL Item
Sonstiges (3)
Item
Erhebungsmodus: Fremdanamnese
integer
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,2])
CL Item
erhoben zusammen mit Mutter (1)
CL Item
erhoben zusammen mit Vater (2)
CL Item
erhoben zusammen mit andere (3)
Type of medical history taking
Item
Erhebungsmodus: Fremdanamnese andere
text
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,2])
Type of medical history taking
Item
Erhebungsmodus: Sonstiges
text
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,2])
Current medical history
Item
Aktuelle Anamnese
text
C0262926 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
C0521116 (UMLS CUI [1,2])
Current medication
Item
Aktuelle Medikation
text
C1553892 (UMLS CUI [1])
Current medication comment
Item
Kommentar zur Medikation:
text
C1553892 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,2])
General medical history
Item
Allgemeine Anamnese
text
C0262926 (UMLS CUI [1])
Immunization status
Item
Impfstatus
text
C0552506 (UMLS CUI [1])
Hypersensitivities
Item
Allergien/Unverträglichkeiten
text
C0020517 (UMLS CUI [1])
Peripartum history
Item
Geburtsanamnese
text
C2053583 (UMLS CUI [1])
Birth Order
Item
Geschwisterfolge:
text
C0005607 (UMLS CUI [1])
Gestational age
Item
Gestationsalter
integer
C0017504 (UMLS CUI [1])
Birth clinic
Item
Geburtsklinik:
text
C1552420 (UMLS CUI [1])
Mode of delivery
Item
Geburtsmodus
text
C1555567 (UMLS CUI [1])
Gender
Item
Geschlecht
text
C0079399 (UMLS CUI [1])
Birth weight
Item
Geburtsgewicht
integer
C0005612 (UMLS CUI [1])
Birth length
Item
Geburtslänge
integer
C0419415 (UMLS CUI [1])
APGAR
Item
APGAR
integer
C0003533 (UMLS CUI [1])
Umbilical cord pH
Item
Nabelschnur-pH
integer
C4067152 (UMLS CUI [1])
Head circumference
Item
Geburtskopfumfang
float
C0262499 (UMLS CUI [1])
Pregnancy course
Item
Schwangerschaftsverlauf
text
C0032961 (UMLS CUI [1,1])
C0750729 (UMLS CUI [1,2])
C0750729 (UMLS CUI [1,2])
Perinatal period
Item
Perinatalperiode
text
C0178795 (UMLS CUI [1])
Vitamin D prophylaxis
Item
Vitamin D Prophylaxe
text
C0420176 (UMLS CUI [1])
Infant feeding method
Item
Ernährung
text
C0420979 (UMLS CUI [1])
Kindergarten
Item
Kindergarten:
text
C0876933 (UMLS CUI [1])
School type
Item
Schulform
text
C1547791 (UMLS CUI [1])
School Grade
Item
Klasse
integer
C3244287 (UMLS CUI [1])
Achievements in school
Item
Schulleistungen
text
C0700132 (UMLS CUI [1])
Month/year of hospital admission
Item
Monat/Jahr
partialDate
C0184666 (UMLS CUI [1,1])
C0680185 (UMLS CUI [1,2])
C0680185 (UMLS CUI [1,2])
Hospital
Item
Welches Krankenhaus
text
C0019994 (UMLS CUI [1])
Indication
Item
Indikation
text
C3146298 (UMLS CUI [1])
Type of surgery
Item
Art der Operation
text
C0543467 (UMLS CUI [1])
Childhood diseases
Item
Kinderkrankheiten
text
C0489532 (UMLS CUI [1])
Mother´s year of birth
Item
Geburtsjahr Mutter
integer
C2319404 (UMLS CUI [1])
Mother´s occupation
Item
Beruf der Mutter
text
C0028811 (UMLS CUI [1,1])
C0026591 (UMLS CUI [1,2])
C0026591 (UMLS CUI [1,2])
Medical history mother
Item
Krankheiten der Mutter
text
C0241889 (UMLS CUI [1,1])
C0026591 (UMLS CUI [1,2])
C0026591 (UMLS CUI [1,2])
Father´s year of birth
Item
Geburtsjahr Vater
integer
C2136977 (UMLS CUI [1])
Father´s occupation
Item
Beruf des Vaters
text
C0028811 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
C0015671 (UMLS CUI [1,2])
Medical history of father
Item
Krankheiten des Vaters
text
C0241889 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
C0015671 (UMLS CUI [1,2])
Siblings
Item
Geschwister
text
C0037047 (UMLS CUI [1])
other
Item
Sonstiges
text
C0205394 (UMLS CUI [1])
VITALS
Item
Vitalparameter in Fieberkurve übertragen
text
C0518766 (UMLS CUI [1])
Body Height
Item
Körpergröße
integer
C0005890 (UMLS CUI [1])
Body weight
Item
Körpergewicht
float
C0005910 (UMLS CUI [1])
Head circumference
Item
Kopfumfang
integer
Body temperature
Item
Körpertemperatur
float
C0005903 (UMLS CUI [1])
Heart rate
Item
Herzfrequenz
integer
C0018810 (UMLS CUI [1])
Systolic bloodpressure
Item
Blutdruck systolisch
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
Diastolischer Blutdruck
integer
C0428883 (UMLS CUI [1])
MAP
Item
MAD
integer
C0428886 (UMLS CUI [1])
Respiratory rate
Item
Atemfrequenz
integer
C0231832 (UMLS CUI [1])
Oxygen saturation
Item
Sauerstoffsättigung:
float
C2237091 (UMLS CUI [1])
Clinical findings
Item
Untersuchungsbefund
text
C0455712 (UMLS CUI [1])
Examiner
Item
Untersucher
text
C0025082 (UMLS CUI [1])
General medical impression
Item
Allgemeiner Eindruck
text
C2973287 (UMLS CUI [1])
SKIN
Item
Haut
text
C0437750 (UMLS CUI [1])
ENT examination
Item
HNO-Inspektion
text
C0278350 (UMLS CUI [1])
Lymph node status
Item
Lymphknotenstatus
text
C0024204 (UMLS CUI [1])
Heart examination
Item
Herz
text
C0018787 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,2])
Circulatory system examination
Item
Kreislauf
text
C0497231 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,2])
Respiratory system examination
Item
Lunge und Atmung
text
C0035237 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,2])
Abdomen examination
Item
Abdomen
text
C0562238 (UMLS CUI [1])
Neurological exam
Item
Neurologie
text
C0027853 (UMLS CUI [1])
Musculoskeletal system examination
Item
Bewegungsapparat
text
C0026860 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,2])
Fontanelle
Item
Fontanelle
text
C0224548 (UMLS CUI [1])
Puberty and genitalia
Item
Genitale und Pubertätsstadien
text
C0429595 (UMLS CUI [1,1])
C0017420 (UMLS CUI [1,2])
C0017420 (UMLS CUI [1,2])
Admission Diagnosis
Item
Aufnahme Diagnose(n)
text
C1628992 (UMLS CUI [1])
Reason for admission
Item
Aufnahmegrund
text
C0184666 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,2])
Accompanying person
Item
Mitaufnahme Begleitperson
boolean
C0868649 (UMLS CUI [1])
Physician orders
Item
Ärztliche Kurzanordnung (KAO)
text
C1546491 (UMLS CUI [1])
Medication review
Item
Medikation aufrufen
text
C0560023 (UMLS CUI [1])
Documentation initial exams and orders
Item
Dokumentation initiale Diagnostik und Anordnungen
text
C0920316 (UMLS CUI [1,1])
C2729337 (UMLS CUI [1,2])
C2729337 (UMLS CUI [1,2])
Differential diagnosis
Item
Differentialdiagnosen
text
C0011906 (UMLS CUI [1])
Medical problems and treatment goals definition
Item
Probleme und Behandlungsziele definieren
text
C0025104 (UMLS CUI [1,1])
C0677092 (UMLS CUI [1,2])
C0677092 (UMLS CUI [1,2])
Hospital course
Item
Verlauf anlegen
text
C0489547 (UMLS CUI [1])
Work-flow
Item
Arbeitsliste-Dekurs anlegen
text
C1710679 (UMLS CUI [1])