ID

18398

Description

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: AN MS MEDD Anamnese KU

Keywords

Versions (2)
  1. 11/3/16 11/3/16 -
  2. 11/13/16 11/13/16 -
Uploaded on

November 3, 2016

DOI

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License

Creative Commons BY-NC 3.0
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AN MS MEDD Anamnese KU University Hospital Muenster (UKM)

German

AN MS MEDD Anamnese KU University Hospital Muenster (UKM)

1 forms  
Allgemeine Angaben
Description

Allgemeine Angaben

Erhoben von
Description

History taken by

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0680379
Erhoben am
Description

Date medical history taken

Data type

date

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0011008
Erhoben um
Description

Time medical history taken

Data type

time

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0040223
Erhebungsmodus
Description

Erhebungsmodus

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Jetzige Anamnese
Description

Present Illness

Data type

text

Alias
UMLS CUI [1]
C0262512
Vorerkrankungen
Description

Pre-existing conditions

Data type

boolean

Alias
UMLS CUI [1]
C0521987
Vorerkrankungen: wenn ja, bitte angeben
Description

Pre-existing conditions

Data type

text

Alias
UMLS CUI [1]
C0521987
Operationen
Description

Surgery

Data type

boolean

Alias
UMLS CUI [1]
C0543467
Operationen: wenn ja, bitte angeben
Description

Surgery

Data type

text

Alias
UMLS CUI [1]
C0543467
Medikamente
Description

Medication

Data type

boolean

Alias
UMLS CUI [1]
C0013227
Medikamente: wenn ja, bitte angeben
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Allgemeine Anamnese
Description

Allgemeine Anamnese

Allergien
Description

Allergies

Data type

boolean

Alias
UMLS CUI [1]
C0020517
Allergien: wenn ja, bitte angeben
Description

Allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
Alkohol
Description

Alcohol

Data type

boolean

Alias
UMLS CUI [1]
C0001948
Alkohol: wenn ja, bitte spezifizieren
Description

Alcohol

Data type

text

Alias
UMLS CUI [1]
C0001948
Nikotin
Description

Tobacco use

Data type

boolean

Alias
UMLS CUI [1]
C0543414
Nikotin: wenn ja, bitte Schachteln/Tag angeben
Description

Packs of cigarettes/day

Data type

float

Alias
UMLS CUI [1]
C3694145
Nikotin: wenn ja, seit wie vielen Jahren?
Description

Years of smoking

Data type

float

Alias
UMLS CUI [1]
C1277691
Ex-Raucher
Description

Former Smoker

Data type

boolean

Alias
UMLS CUI [1]
C0337671
Ex-Raucher: wenn ja, seit wie vielen Jahren?
Description

Time since stopped smoking

Data type

float

Alias
UMLS CUI [1]
C0453997
Nikotin: wenn ja, bitte spezifizieren
Description

Tobacco use

Data type

text

Alias
UMLS CUI [1]
C0543414
Hypercholesterinämie:
Description

Hypercholesterolemia

Data type

boolean

Alias
UMLS CUI [1]
C0020443
Hypercholesterinämie: wenn ja, bitte spezifizieren
Description

Hypercholesterolemia

Data type

text

Alias
UMLS CUI [1]
C0020443
Diabetes
Description

Diabetes

Data type

boolean

Alias
UMLS CUI [1]
C0011849
Diabetes: wenn ja, bitte spezifizieren
Description

Diabetes

Data type

text

Alias
UMLS CUI [1]
C0011849
Sonstige Risikofaktoren
Description

Other risk factors

Data type

boolean

Alias
UMLS CUI [1]
C0035648
Sonstige Risikofaktoren: wenn ja, bitte spezifizieren
Description

Other risk factors

Data type

text

Alias
UMLS CUI [1]
C0035648
Familienkrankheiten: Mutter
Description

Family history: Mother

Data type

text

Alias
UMLS CUI [1]
C0424914
Familienkrankheiten: Father
Description

Family history: Father

Data type

text

Alias
UMLS CUI [1]
C0424909
Familienkrankheiten: Sonstige
Description

Family history: Other relative

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C3174795
Soziale Anamnese
Description

Soziale Anamnese

Beruf
Description

Occupation

Data type

text

Alias
UMLS CUI [1]
C0421456
Familienstand
Description

Marital Status

Data type

integer

Alias
UMLS CUI [1]
C0024819
Anzahl der Kinder
Description

Number of children

Data type

integer

Alias
UMLS CUI [1]
C2229974
Hobbies
Description

Hobbies

Data type

text

Alias
UMLS CUI [1]
C0019826
Berufliche Probleme
Description

Problems at work

Data type

text

Alias
UMLS CUI [1]
C0425101
Persönliche Probleme
Description

Personal Problems

Data type

text

Alias
UMLS CUI [1]
C0577645
Häusliche Situation
Description

Home environment

Data type

boolean

Alias
UMLS CUI [1]
C0442519
Häusliche Situation: wenn ja, bitte spezifizieren
Description

Home environment

Data type

text

Alias
UMLS CUI [1]
C0442519
Sonstige Anamnese
Description

Social history: other

Data type

text

Alias
UMLS CUI [1,1]
C3714536
UMLS CUI [1,2]
C0205394
Vegetative Anamnese
Description

Vegetative Anamnese

Größe
Description

Height

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Gewicht
Description

body weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
BMI
Description

BMI

Data type

float

Alias
UMLS CUI [1]
C1305855
Gewichtsveränderung
Description

Body weight change

Data type

boolean

Alias
UMLS CUI [1]
C0005911
Gewichtsveränderung: wenn ja, bitte spezifizieren
Description

Body weight change

Data type

text

Alias
UMLS CUI [1]
C0005911
Stuhlgang
Description

Bowel movement

Data type

boolean

Alias
UMLS CUI [1]
C0011135
Stuhlgang: wenn ja, bitte spezifizieren
Description

Bowel movement

Data type

text

Alias
UMLS CUI [1]
C0011135
Miktion
Description

Urination

Data type

boolean

Alias
UMLS CUI [1]
C0042034
Miktion: wenn ja, bitte spezifizieren
Description

Miction

Data type

text

Alias
UMLS CUI [1]
C0042034
Nykturie
Description

Nocturia

Data type

boolean

Alias
UMLS CUI [1]
C0028734
Nykturie: wenn ja, bitte spezifizieren
Description

Nocturia

Data type

text

Alias
UMLS CUI [1]
C0028734
Nachtschweiß
Description

Night sweats

Data type

boolean

Alias
UMLS CUI [1]
C0028081
Nachtschweiß: wenn ja, bitte spezifizieren
Description

Night sweats

Data type

text

Alias
UMLS CUI [1]
C0028081
Fieber
Description

Fever

Data type

boolean

Alias
UMLS CUI [1]
C0015967
Fieber: wenn ja, bitte spezifizieren
Description

Fever

Data type

text

Alias
UMLS CUI [1]
C0015967
Luftnot
Description

Dyspnea

Data type

boolean

Alias
UMLS CUI [1]
C0013404
Luftnot: wenn ja, bitte spezifizieren
Description

Dyspnea

Data type

text

Alias
UMLS CUI [1]
C0013404
Ödeme
Description

Edema

Data type

boolean

Alias
UMLS CUI [1]
C0013604
Ödeme: wenn ja, bitte spezifizieren
Description

Edema

Data type

text

Alias
UMLS CUI [1]
C0013604
Husten
Description

Coughing

Data type

boolean

Alias
UMLS CUI [1]
C0010200
Husten: wenn ja, bitte spezifizieren
Description

Coughing

Data type

text

Alias
UMLS CUI [1]
C0010200
Auswurf
Description

Productive cough

Data type

boolean

Alias
UMLS CUI [1]
C0239134
Auswurf: wenn ja, bitte spezifizieren
Description

Productive cough

Data type

text

Alias
UMLS CUI [1]
C0239134
Gelenkbeschwerden
Description

Arthropathy

Data type

boolean

Alias
UMLS CUI [1]
C0022408
Gelenkbeschwerden: wenn ja, bitte spezifizieren
Description

Arthropathy

Data type

text

Alias
UMLS CUI [1]
C0022408
Vaskulitiszeichen
Description

Signs of vasculitis

Data type

boolean

Alias
UMLS CUI [1,1]
C0042384
UMLS CUI [1,2]
C0037088
Vaskulitiszeichen: wenn ja, bitte spezifizieren
Description

Signs of vasculitis

Data type

text

Alias
UMLS CUI [1,1]
C0042384
UMLS CUI [1,2]
C0037088
Hypertonus
Description

Hypertension

Data type

boolean

Alias
UMLS CUI [1]
C0020538
Hypertonus: wenn ja, bitte spezifizieren
Description

Hypertension

Data type

text

Alias
UMLS CUI [1]
C0020538
Appetit
Description

Appetite

Data type

boolean

Alias
UMLS CUI [1]
C0003618
Appetit: wenn ja, bitte spezifizieren
Description

Appetite

Data type

text

Alias
UMLS CUI [1]
C0003618
Schlaf
Description

Sleep

Data type

boolean

Alias
UMLS CUI [1]
C0037313
Schlaf: wenn ja, bitte spezifizieren
Description

Sleep

Data type

text

Alias
UMLS CUI [1]
C0037313
Trinkmenge
Description

Fluid intake

Data type

float

Measurement units
  • l/Tag
Alias
UMLS CUI [1]
C0429791
l/Tag
Trinkmenge: bitte spezifizieren
Description

Fluid intake

Data type

text

Alias
UMLS CUI [1]
C0429791
Eigendiurese
Description

Diuresis

Data type

float

Measurement units
  • l/Tag
Alias
UMLS CUI [1]
C0012797
l/Tag
Eigendiurese: bitte spezifizieren
Description

Diuresis

Data type

text

Alias
UMLS CUI [1]
C0012797
Sonstiges
Description

Review of systems: other

Data type

text

Alias
UMLS CUI [1,1]
C0489633
UMLS CUI [1,2]
C0205394
Klinische Untersuchung
Description

Klinische Untersuchung

Allgemeinbefund
Description

Examination finding

Data type

boolean

Alias
UMLS CUI [1]
C0031809
Allgemeinbefund: wenn ja, bitte spezifizieren
Description

Examination finding

Data type

text

Alias
UMLS CUI [1]
C0031809
Kopf
Description

Head

Data type

boolean

Alias
UMLS CUI [1]
C2239107
Kopf: wenn ja, bitte spezifizieren
Description

Head

Data type

text

Alias
UMLS CUI [1]
C2239107
Hals
Description

Neck

Data type

boolean

Alias
UMLS CUI [1]
C2228463
Hals: wenn ja, bitte spezifizieren
Description

Neck

Data type

text

Alias
UMLS CUI [1]
C2228463
Thorax
Description

Chest

Data type

boolean

Alias
UMLS CUI [1]
C0850563
Thorax: wenn ja, bitte spezifizieren
Description

Chest

Data type

text

Alias
UMLS CUI [1]
C0850563
Lunge
Description

Lungs

Data type

boolean

Alias
UMLS CUI [1]
C2228454
Lunge: wenn ja, bitte spezifizieren
Description

Lungs

Data type

text

Alias
UMLS CUI [1]
C2228454
Herz und Gefäßsystem
Description

Cardiovascular

Data type

boolean

Alias
UMLS CUI [1]
C3854344
Herz und Gefäßsystem: wenn ja, bitte spezifizieren
Description

Cardiovascular

Data type

text

Alias
UMLS CUI [1]
C3854344
Cor
Description

Heart

Data type

boolean

Alias
UMLS CUI [1]
C0562319
Cor: wenn ja, bitte spezifizieren
Description

Heart

Data type

text

Alias
UMLS CUI [1]
C0562319
Pulsstatus
Description

Pulse

Data type

boolean

Alias
UMLS CUI [1]
C0558829
Pulsstatus: wenn ja, bitte spezifizieren
Description

Pulse

Data type

text

Alias
UMLS CUI [1]
C0558829
Obere Extremität o.p.B.
Description

Pulse upper extremity - NAD

Data type

boolean

Alias
UMLS CUI [1,1]
C0558829
UMLS CUI [1,2]
C1140618
UMLS CUI [1,3]
C0559229
Pulsstatus: Carotis rechts
Description

Pulse: Right common carotid artery

Data type

text

Alias
UMLS CUI [1,1]
C1096529
UMLS CUI [1,2]
C0205090
Pulsstatus: Carotis links
Description

Pulse: Left common carotid artery

Data type

text

Alias
UMLS CUI [1,1]
C1096529
UMLS CUI [1,2]
C0205091
Pulsstatus: Radialis rechts
Description

Pulse: Right radial artery

Data type

text

Alias
UMLS CUI [1,1]
C2363059
UMLS CUI [1,2]
C0205090
Pulsstatus: Radialis links
Description

Pulse: Left radial artery

Data type

text

Alias
UMLS CUI [1,1]
C2363059
UMLS CUI [1,2]
C0205091
Untere Extremität o.p.B.
Description

Pulse lower extremity - NAD

Data type

boolean

Alias
UMLS CUI [1,1]
C0558829
UMLS CUI [1,2]
C0023216
UMLS CUI [1,3]
C0559229
Pulsstatus: Femoralis rechts
Description

Pulse: Right femoral artery

Data type

text

Alias
UMLS CUI [1]
C2228442
Pulsstatus: Femoralis links
Description

Pulse: Left femoral artery

Data type

text

Alias
UMLS CUI [1]
C2228442
Pulsstatus: Poplitea rechts
Description

Pulse: Right popliteal artery

Data type

text

Alias
UMLS CUI [1,1]
C0232151
UMLS CUI [1,2]
C0205090
Pulsstatus: Poplitea links
Description

Pulse: Left popliteal artery

Data type

text

Alias
UMLS CUI [1,1]
C0232151
UMLS CUI [1,2]
C0205091
Pulsstatus: Tibialis posterior rechts
Description

Pulse: Right posterior tibial artery

Data type

text

Alias
UMLS CUI [1,1]
C2112498
UMLS CUI [1,2]
C0205090
Pulsstatus: Tibialis posterior links
Description

Pulse: Left posterior tibial artery

Data type

text

Alias
UMLS CUI [1,1]
C2112498
UMLS CUI [1,2]
C0205091
Pulsstatus: Dorsalis pedis rechts
Description

Pulse: Right dorsalis pedis artery

Data type

text

Alias
UMLS CUI [1,1]
C2228434
UMLS CUI [1,2]
C0205090
Pulsstatus: Dorsalis pedis rechts
Description

Pulse: Right dorsalis pedis artery

Data type

text

Alias
UMLS CUI [1,1]
C2228434
UMLS CUI [1,2]
C0205090
Blutdruck rechts
Description

Blood Pressure - right

Data type

float

Measurement units
  • mmHg
Alias
UMLS CUI [1,1]
C0005823
UMLS CUI [1,2]
C0229966
mmHg
Blutdruck rechts
Description

Blood Pressure - left

Data type

float

Measurement units
  • mmHg
Alias
UMLS CUI [1,1]
C0005823
UMLS CUI [1,2]
C0229967
mmHg
Abdomen
Description

Abdomen

Data type

boolean

Alias
UMLS CUI [1]
C0562238
Abdomen
Description

Abdomen

Data type

text

Alias
UMLS CUI [1]
C0562238
Urogenitalsystem/Rektum
Description

Urogenitalsystem/Rektum

Data type

boolean

Alias
UMLS CUI [1]
C0555350
UMLS CUI [2]
C0199900
Urogenitalsystem/Rektum: wenn ja, bitte spezifizieren
Description

Urogenitalsystem/Rektum

Data type

text

Alias
UMLS CUI [1]
C0555350
UMLS CUI [2]
C0199900
Extremitäten
Description

Extremities

Data type

boolean

Alias
UMLS CUI [1]
C0436150
Extremitäten: wenn ja, bitte spezifizieren
Description

Extremities

Data type

text

Alias
UMLS CUI [1]
C0436150
Wirbelsäule
Description

Vertebral column

Data type

boolean

Alias
UMLS CUI [1]
C0037949
Wirbelsäule: wenn ja, bitte spezifizieren
Description

Vertebral column

Data type

text

Alias
UMLS CUI [1]
C0037949
Nervensystem und Psyche
Description

Nervous system and mental state

Data type

boolean

Alias
UMLS CUI [1]
C0027853
UMLS CUI [2]
C0278060
Nervensystem und Psyche: wenn ja, bitte spezifizieren
Description

Nervous system and mental state

Data type

text

Alias
UMLS CUI [1]
C0027853
UMLS CUI [2]
C0278060
Lymphknoten
Description

Lymph nodes

Data type

boolean

Alias
UMLS CUI [1]
C0562297
Lymphknoten: wenn ja, bitte spezifizieren
Description

Lymph nodes

Data type

text

Alias
UMLS CUI [1]
C0562297
Sonstiges
Description

Physical Examination: other

Data type

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0205394
Sonstiges: : wenn ja, bitte spezifizieren
Description

Physical Examination: other

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0205394
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Similar models

AN MS MEDD Anamnese KU University Hospital Muenster (UKM)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Allgemeine Angaben
History taken by
Item
Erhoben von
text
C0025084 (UMLS CUI [1,1])
C0680379 (UMLS CUI [1,2])
Date medical history taken
Item
Erhoben am
date
C0025084 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Time medical history taken
Item
Erhoben um
time
C0025084 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Erhebungsmodus
Item
Erhebungsmodus
text
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Present Illness
Item
Jetzige Anamnese
text
C0262512 (UMLS CUI [1])
Pre-existing conditions
Item
Vorerkrankungen
boolean
C0521987 (UMLS CUI [1])
Pre-existing conditions
Item
Vorerkrankungen: wenn ja, bitte angeben
text
C0521987 (UMLS CUI [1])
Surgery
Item
Operationen
boolean
C0543467 (UMLS CUI [1])
Surgery
Item
Operationen: wenn ja, bitte angeben
text
C0543467 (UMLS CUI [1])
Medication
Item
Medikamente
boolean
C0013227 (UMLS CUI [1])
Medication
Item
Medikamente: wenn ja, bitte angeben
text
C0013227 (UMLS CUI [1])
Item Group
Allgemeine Anamnese
Allergies
Item
Allergien
boolean
C0020517 (UMLS CUI [1])
Allergies
Item
Allergien: wenn ja, bitte angeben
text
C0020517 (UMLS CUI [1])
Alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
Alcohol
Item
Alkohol: wenn ja, bitte spezifizieren
text
C0001948 (UMLS CUI [1])
Tobacco use
Item
Nikotin
boolean
C0543414 (UMLS CUI [1])
Packs of cigarettes/day
Item
Nikotin: wenn ja, bitte Schachteln/Tag angeben
float
C3694145 (UMLS CUI [1])
Years of smoking
Item
Nikotin: wenn ja, seit wie vielen Jahren?
float
C1277691 (UMLS CUI [1])
Former Smoker
Item
Ex-Raucher
boolean
C0337671 (UMLS CUI [1])
Time since stopped smoking
Item
Ex-Raucher: wenn ja, seit wie vielen Jahren?
float
C0453997 (UMLS CUI [1])
Tobacco use
Item
Nikotin: wenn ja, bitte spezifizieren
text
C0543414 (UMLS CUI [1])
Hypercholesterolemia
Item
Hypercholesterinämie:
boolean
C0020443 (UMLS CUI [1])
Hypercholesterolemia
Item
Hypercholesterinämie: wenn ja, bitte spezifizieren
text
C0020443 (UMLS CUI [1])
Diabetes
Item
Diabetes
boolean
C0011849 (UMLS CUI [1])
Diabetes
Item
Diabetes: wenn ja, bitte spezifizieren
text
C0011849 (UMLS CUI [1])
Other risk factors
Item
Sonstige Risikofaktoren
boolean
C0035648 (UMLS CUI [1])
Other risk factors
Item
Sonstige Risikofaktoren: wenn ja, bitte spezifizieren
text
C0035648 (UMLS CUI [1])
Family history: Mother
Item
Familienkrankheiten: Mutter
text
C0424914 (UMLS CUI [1])
Family history: Father
Item
Familienkrankheiten: Father
text
C0424909 (UMLS CUI [1])
Family history: Other relative
Item
Familienkrankheiten: Sonstige
text
C0241889 (UMLS CUI [1,1])
C3174795 (UMLS CUI [1,2])
Item Group
Soziale Anamnese
Occupation
Item
Beruf
text
C0421456 (UMLS CUI [1])
Item
Familienstand
integer
C0024819 (UMLS CUI [1])
Marital Status
Code List
Familienstand
CL Item
verheiratet (1)
CL Item
ledig (2)
CL Item
geschieden (3)
CL Item
getrennt (4)
CL Item
verwitwet (5)
CL Item
unbekannt (6)
Number of children
Item
Anzahl der Kinder
integer
C2229974 (UMLS CUI [1])
Hobbies
Item
Hobbies
text
C0019826 (UMLS CUI [1])
Problems at work
Item
Berufliche Probleme
text
C0425101 (UMLS CUI [1])
Personal Problems
Item
Persönliche Probleme
text
C0577645 (UMLS CUI [1])
Home environment
Item
Häusliche Situation
boolean
C0442519 (UMLS CUI [1])
Home environment
Item
Häusliche Situation: wenn ja, bitte spezifizieren
text
C0442519 (UMLS CUI [1])
Social history: other
Item
Sonstige Anamnese
text
C3714536 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Vegetative Anamnese
Height
Item
Größe
float
C0005890 (UMLS CUI [1])
body weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
BMI
Item
BMI
float
C1305855 (UMLS CUI [1])
Body weight change
Item
Gewichtsveränderung
boolean
C0005911 (UMLS CUI [1])
Body weight change
Item
Gewichtsveränderung: wenn ja, bitte spezifizieren
text
C0005911 (UMLS CUI [1])
Bowel movement
Item
Stuhlgang
boolean
C0011135 (UMLS CUI [1])
Bowel movement
Item
Stuhlgang: wenn ja, bitte spezifizieren
text
C0011135 (UMLS CUI [1])
Urination
Item
Miktion
boolean
C0042034 (UMLS CUI [1])
Miction
Item
Miktion: wenn ja, bitte spezifizieren
text
C0042034 (UMLS CUI [1])
Nocturia
Item
Nykturie
boolean
C0028734 (UMLS CUI [1])
Nocturia
Item
Nykturie: wenn ja, bitte spezifizieren
text
C0028734 (UMLS CUI [1])
Night sweats
Item
Nachtschweiß
boolean
C0028081 (UMLS CUI [1])
Night sweats
Item
Nachtschweiß: wenn ja, bitte spezifizieren
text
C0028081 (UMLS CUI [1])
Fever
Item
Fieber
boolean
C0015967 (UMLS CUI [1])
Fever
Item
Fieber: wenn ja, bitte spezifizieren
text
C0015967 (UMLS CUI [1])
Dyspnea
Item
Luftnot
boolean
C0013404 (UMLS CUI [1])
Dyspnea
Item
Luftnot: wenn ja, bitte spezifizieren
text
C0013404 (UMLS CUI [1])
Edema
Item
Ödeme
boolean
C0013604 (UMLS CUI [1])
Edema
Item
Ödeme: wenn ja, bitte spezifizieren
text
C0013604 (UMLS CUI [1])
Coughing
Item
Husten
boolean
C0010200 (UMLS CUI [1])
Coughing
Item
Husten: wenn ja, bitte spezifizieren
text
C0010200 (UMLS CUI [1])
Productive cough
Item
Auswurf
boolean
C0239134 (UMLS CUI [1])
Productive cough
Item
Auswurf: wenn ja, bitte spezifizieren
text
C0239134 (UMLS CUI [1])
Arthropathy
Item
Gelenkbeschwerden
boolean
C0022408 (UMLS CUI [1])
Arthropathy
Item
Gelenkbeschwerden: wenn ja, bitte spezifizieren
text
C0022408 (UMLS CUI [1])
Signs of vasculitis
Item
Vaskulitiszeichen
boolean
C0042384 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])
Signs of vasculitis
Item
Vaskulitiszeichen: wenn ja, bitte spezifizieren
text
C0042384 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])
Hypertension
Item
Hypertonus
boolean
C0020538 (UMLS CUI [1])
Hypertension
Item
Hypertonus: wenn ja, bitte spezifizieren
text
C0020538 (UMLS CUI [1])
Appetite
Item
Appetit
boolean
C0003618 (UMLS CUI [1])
Appetite
Item
Appetit: wenn ja, bitte spezifizieren
text
C0003618 (UMLS CUI [1])
Sleep
Item
Schlaf
boolean
C0037313 (UMLS CUI [1])
Sleep
Item
Schlaf: wenn ja, bitte spezifizieren
text
C0037313 (UMLS CUI [1])
Fluid intake
Item
Trinkmenge
float
C0429791 (UMLS CUI [1])
Fluid intake
Item
Trinkmenge: bitte spezifizieren
text
C0429791 (UMLS CUI [1])
Diuresis
Item
Eigendiurese
float
C0012797 (UMLS CUI [1])
Diuresis
Item
Eigendiurese: bitte spezifizieren
text
C0012797 (UMLS CUI [1])
Review of systems: other
Item
Sonstiges
text
C0489633 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Klinische Untersuchung
Examination finding
Item
Allgemeinbefund
boolean
C0031809 (UMLS CUI [1])
Examination finding
Item
Allgemeinbefund: wenn ja, bitte spezifizieren
text
C0031809 (UMLS CUI [1])
Head
Item
Kopf
boolean
C2239107 (UMLS CUI [1])
Head
Item
Kopf: wenn ja, bitte spezifizieren
text
C2239107 (UMLS CUI [1])
Neck
Item
Hals
boolean
C2228463 (UMLS CUI [1])
Neck
Item
Hals: wenn ja, bitte spezifizieren
text
C2228463 (UMLS CUI [1])
Chest
Item
Thorax
boolean
C0850563 (UMLS CUI [1])
Chest
Item
Thorax: wenn ja, bitte spezifizieren
text
C0850563 (UMLS CUI [1])
Lungs
Item
Lunge
boolean
C2228454 (UMLS CUI [1])
Lungs
Item
Lunge: wenn ja, bitte spezifizieren
text
C2228454 (UMLS CUI [1])
Cardiovascular
Item
Herz und Gefäßsystem
boolean
C3854344 (UMLS CUI [1])
Cardiovascular
Item
Herz und Gefäßsystem: wenn ja, bitte spezifizieren
text
C3854344 (UMLS CUI [1])
Heart
Item
Cor
boolean
C0562319 (UMLS CUI [1])
Heart
Item
Cor: wenn ja, bitte spezifizieren
text
C0562319 (UMLS CUI [1])
Pulse
Item
Pulsstatus
boolean
C0558829 (UMLS CUI [1])
Pulse
Item
Pulsstatus: wenn ja, bitte spezifizieren
text
C0558829 (UMLS CUI [1])
Pulse upper extremity - NAD
Item
Obere Extremität o.p.B.
boolean
C0558829 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])
C0559229 (UMLS CUI [1,3])
Pulse: Right common carotid artery
Item
Pulsstatus: Carotis rechts
text
C1096529 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Pulse: Left common carotid artery
Item
Pulsstatus: Carotis links
text
C1096529 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Pulse: Right radial artery
Item
Pulsstatus: Radialis rechts
text
C2363059 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Pulse: Left radial artery
Item
Pulsstatus: Radialis links
text
C2363059 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Pulse lower extremity - NAD
Item
Untere Extremität o.p.B.
boolean
C0558829 (UMLS CUI [1,1])
C0023216 (UMLS CUI [1,2])
C0559229 (UMLS CUI [1,3])
Pulse: Right femoral artery
Item
Pulsstatus: Femoralis rechts
text
C2228442 (UMLS CUI [1])
Pulse: Left femoral artery
Item
Pulsstatus: Femoralis links
text
C2228442 (UMLS CUI [1])
Pulse: Right popliteal artery
Item
Pulsstatus: Poplitea rechts
text
C0232151 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Pulse: Left popliteal artery
Item
Pulsstatus: Poplitea links
text
C0232151 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Pulse: Right posterior tibial artery
Item
Pulsstatus: Tibialis posterior rechts
text
C2112498 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Pulse: Left posterior tibial artery
Item
Pulsstatus: Tibialis posterior links
text
C2112498 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Pulse: Right dorsalis pedis artery
Item
Pulsstatus: Dorsalis pedis rechts
text
C2228434 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Pulse: Right dorsalis pedis artery
Item
Pulsstatus: Dorsalis pedis rechts
text
C2228434 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Blood Pressure - right
Item
Blutdruck rechts
float
C0005823 (UMLS CUI [1,1])
C0229966 (UMLS CUI [1,2])
Blood Pressure - left
Item
Blutdruck rechts
float
C0005823 (UMLS CUI [1,1])
C0229967 (UMLS CUI [1,2])
Abdomen
Item
Abdomen
boolean
C0562238 (UMLS CUI [1])
Abdomen
Item
Abdomen
text
C0562238 (UMLS CUI [1])
Urogenitalsystem/Rektum
Item
Urogenitalsystem/Rektum
boolean
C0555350 (UMLS CUI [1])
C0199900 (UMLS CUI [2])
Urogenitalsystem/Rektum
Item
Urogenitalsystem/Rektum: wenn ja, bitte spezifizieren
text
C0555350 (UMLS CUI [1])
C0199900 (UMLS CUI [2])
Extremities
Item
Extremitäten
boolean
C0436150 (UMLS CUI [1])
Extremities
Item
Extremitäten: wenn ja, bitte spezifizieren
text
C0436150 (UMLS CUI [1])
Vertebral column
Item
Wirbelsäule
boolean
C0037949 (UMLS CUI [1])
Vertebral column
Item
Wirbelsäule: wenn ja, bitte spezifizieren
text
C0037949 (UMLS CUI [1])
Nervous system and mental state
Item
Nervensystem und Psyche
boolean
C0027853 (UMLS CUI [1])
C0278060 (UMLS CUI [2])
Nervous system and mental state
Item
Nervensystem und Psyche: wenn ja, bitte spezifizieren
text
C0027853 (UMLS CUI [1])
C0278060 (UMLS CUI [2])
Lymph nodes
Item
Lymphknoten
boolean
C0562297 (UMLS CUI [1])
Lymph nodes
Item
Lymphknoten: wenn ja, bitte spezifizieren
text
C0562297 (UMLS CUI [1])
Physical Examination: other
Item
Sonstiges
boolean
C0031809 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Physical Examination: other
Item
Sonstiges: : wenn ja, bitte spezifizieren
text
C0031809 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
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