ID

18679

Description

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

Keywords

Versions (2)
  1. 11/15/16 11/15/16 -
  2. 11/30/16 11/30/16 -
Uploaded on

November 15, 2016

DOI

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License

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

German English

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

1 forms  
General information
Description

General information

Examiner
Description

Examiner

Data type

text

Date of medical history taking
Description

Date of medical history taking

Data type

date

Mode of medical history taking
Description

Mode of medical history taking

Data type

text

Current medical history
Description

Current medical history

Data type

text

Vegetative anamnesis and management of risk factors
Description

Vegetative anamnesis and management of risk factors

Height
Description

Height

Data type

float

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

Weight

Data type

float

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

BMI

Data type

text

Change in weight
Description

Change in weight

Data type

boolean

Change in weight (specification)
Description

Change in weight (specification)

Data type

text

Amount of liquid consumed (per day)
Description

Amount of liquid consumed (per day)

Data type

float

Measurement units
  • l
l
Amount of liquid consumed (specification)
Description

Amount of liquid consumed (specification)

Data type

text

Diuresis (per day)
Description

Diuresis (per day)

Data type

float

Measurement units
  • l
l
Diuresis
Description

Diuresis

Data type

text

Hypertension: Mean systolic blood pressure
Description

Hypertension: Mean systolic blood pressure

Data type

integer

Hypertension: systolic
Description

Hypertension: systolic

Data type

text

Hypertension: Mean diastolic blood pressure
Description

Hypertension: Mean diastolic blood pressure

Data type

integer

Hypertension: diastolic
Description

Hypertension: diastolic

Data type

text

Hypertension: 24 h RR (syst/diast)
Description

Hypertension: 24 h RR (syst/diast)

Data type

text

Hypertension: Date of 24 h RR measurement
Description

Hypertension: Date of 24 h RR measurement

Data type

date

Hypertension: Comments 24 h RR
Description

Hypertension: Comments 24 h RR

Data type

text

Fever
Description

Fever

Data type

boolean

Fever (specification)
Description

Fever (specification)

Data type

text

Stool
Description

Stool

Data type

boolean

Stool (specification)
Description

Stool (specification)

Data type

text

Micturition
Description

Micturition

Data type

boolean

Micturition (specification)
Description

Micturition (specification)

Data type

text

Nocturia
Description

Nocturia

Data type

boolean

Nocturia (specification)
Description

Nocturia (specification)

Data type

text

Coughing
Description

Coughing

Data type

boolean

Coughing (specification)
Description

Coughing (specification)

Data type

text

Sputum
Description

Sputum

Data type

boolean

Sputum (specification)
Description

Sputum (specification)

Data type

text

Shortness of breath
Description

Shortness of breath

Data type

boolean

Shortness of breath (specification)
Description

Shortness of breath (specification)

Data type

text

Edemata
Description

Edemata

Data type

boolean

Edemata (specification)
Description

Edemata (specification)

Data type

text

Night sweats
Description

Night sweats

Data type

boolean

Night sweats (specification)
Description

Night sweats (specification)

Data type

text

Joint trouble
Description

Joint trouble

Data type

boolean

Joint trouble (specification)
Description

Joint trouble (specification)

Data type

text

Signs of vasculitis
Description

Signs of vasculitis

Data type

boolean

Signs of vasculitis (specification)
Description

Signs of vasculitis (specification)

Data type

text

Appetite
Description

Appetite

Data type

boolean

Appetite (specification)
Description

Appetite (specification)

Data type

text

Sleep
Description

Sleep

Data type

boolean

Sleep (specification)
Description

Sleep (specification)

Data type

text

Nicotine
Description

Nicotine

Data type

boolean

Nicotine: packets per day
Description

Nicotine: packets per day

Data type

float

Nicotine: duration of consumption (years)
Description

Nicotine: duration of consumption (years)

Data type

float

Measurement units
  • years
years
Nicotine: Ex-smoker
Description

Nicotine: Ex-smoker

Data type

boolean

Nicotine: Ex-smoker since (years)
Description

Nicotine: Ex-smoker since (years)

Data type

float

Measurement units
  • years
years
Nicotine (specification)
Description

Nicotine (specification)

Data type

text

Alcohol
Description

Alcohol

Data type

boolean

Alcohol (specification)
Description

Alcohol (specification)

Data type

text

Hypercholesterolemia
Description

Hypercholesterolemia

Data type

boolean

Hypercholesterolemia (specification)
Description

Hypercholesterolemia (specification)

Data type

text

Diabetes
Description

Diabetes

Data type

boolean

Diabetes (specification)
Description

Diabetes (specification)

Data type

text

Calcium/phosphate balance
Description

Calcium/phosphate balance

Data type

boolean

Calcium/phosphate balance (specification)
Description

Calcium/phosphate balance (specification)

Data type

text

Other risk factors
Description

Other risk factors

Data type

boolean

Other risk factors (specification)
Description

Other risk factors (specification)

Data type

text

Clinical examination
Description

Clinical examination

General findings/skin
Description

General findings/skin

Data type

boolean

General findings/skin (specification)
Description

General findings/skin (specification)

Data type

text

Head
Description

Head

Data type

boolean

Head (specification)
Description

Head (specification)

Data type

text

Neck
Description

Neck

Data type

boolean

Neck (specification)
Description

Neck (specification)

Data type

text

Thorax
Description

Thorax

Data type

boolean

Thorax (specification)
Description

Thorax (specification)

Data type

text

Lungs
Description

Lungs

Data type

boolean

Lungs (specification)
Description

Lungs (specification)

Data type

text

Cardiovascular system
Description

Cardiovascular system

Data type

boolean

Cardiovascular system (specification)
Description

Cardiovascular system (specification)

Data type

text

Heart
Description

Heart

Data type

boolean

Heart (specification)
Description

Heart (specification)

Data type

text

Pulse status
Description

Pulse status

Data type

boolean

Pulse status (specification)
Description

Pulse status (specification)

Data type

text

Pulse status: Upper limb N.A.D.
Description

Pulse status: Upper limb N.A.D.

Data type

boolean

Pulse status: Right carotid artery
Description

Pulse status: Right carotid artery

Data type

text

Pulse status: Left carotid artery
Description

Pulse status: Left carotid artery

Data type

text

Pulse status: Right radial artery
Description

Pulse status: Right radial artery

Data type

text

Pulse status: Left radial artery
Description

Pulse status: Left radial artery

Data type

text

Pulse status: Lower limb N.A.D.
Description

Pulse status: Lower limb N.A.D.

Data type

boolean

Pulse status: Right femoral artery
Description

Pulse status: Right femoral artery

Data type

text

Pulse status: Left femoral artery
Description

Pulse status: Left femoral artery

Data type

text

Pulse status: Right popliteal artery
Description

Pulse status: Right popliteal artery

Data type

text

Pulse status: Left popliteal artery
Description

Pulse status: Left popliteal artery

Data type

text

Pulse status: Right posterior tibial artery
Description

Pulse status: Right posterior tibial artery

Data type

text

Pulse status: Left posterior tibial artery
Description

Pulse status: Left posterior tibial artery

Data type

text

Pulse status: Right dorsalis pedis artery
Description

Pulse status: Right dorsalis pedis artery

Data type

text

Pulse status: Left dorsalis pedis artery
Description

Pulse status: Left dorsalis pedis artery

Data type

text

Blood pressure right
Description

Blood pressure right

Data type

text

Measurement units
  • mmHg
mmHg
Blood pressure left
Description

Blood pressure left

Data type

text

Measurement units
  • mmHg
mmHg
Transplant
Description

Transplant

Data type

boolean

Transplant (specification)
Description

Transplant (specification)

Data type

text

Abdomen
Description

Abdomen

Data type

boolean

Abdomen (specification)
Description

Abdomen (specification)

Data type

text

Genitourinary system / rectum
Description

Genitourinary system / rectum

Data type

boolean

Genitourinary system / rectum (specification)
Description

Genitourinary system / rectum (specification)

Data type

text

Limbs/edema
Description

Limbs/edema

Data type

boolean

Limbs/edema (specification)
Description

Limbs/edema (specification)

Data type

text

Spine
Description

Spine

Data type

boolean

Spine (specification)
Description

Spine (specification)

Data type

text

Nervous system and psyche
Description

Nervous system and psyche

Data type

boolean

Nervous system and psyche (specification)
Description

Nervous system and psyche (specification)

Data type

text

Lymph nodes
Description

Lymph nodes

Data type

boolean

Lymph nodes (specification)
Description

Lymph nodes (specification)

Data type

text

Other
Description

Other

Data type

boolean

Other (specification)
Description

Other (specification)

Data type

text

Wound
Description

Wound

Data type

boolean

Wound (specification)
Description

Wound (specification)

Data type

text

Sonography of transplanted kidney
Description

Sonography of transplanted kidney

Morphology (qualitative)
Description

Morphology (qualitative)

Data type

text

Longitudinal diameter
Description

Longitudinal diameter

Data type

integer

Measurement units
  • mm
mm
Lateral diameter
Description

Lateral diameter

Data type

integer

Measurement units
  • mm
mm
Width of parenchyma
Description

Width of parenchyma

Data type

integer

Measurement units
  • mm
mm
Doppler/Duplex sonography
Description

Doppler/Duplex sonography

Data type

text

Resistive index
Description

Resistive index

Data type

text

Renal arteries Vmax
Description

Renal arteries Vmax

Data type

integer

Measurement units
  • cm/s
cm/s
Quality of flow in renal artery
Description

Quality of flow in renal artery

Data type

text

Other
Description

Other

Data type

text

Summary/Procedure
Description

Summary/Procedure

Procedure
Description

Procedure

Data type

text

Summary of medical history
Description

Summary of medical history

Data type

text

Summary of clinical examination
Description

Summary of clinical examination

Data type

text

Summary of sonography
Description

Summary of sonography

Data type

text

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Similar models

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Examiner
Item
text
Date of medical history taking
Item
date
Mode of medical history taking
Item
text
Current medical history
Item
text
Height
Item
float
C0005890 (UMLS CUI [1])
Weight
Item
float
C0005910 (UMLS CUI [1])
BMI
Item
text
Change in weight
Item
boolean
Change in weight (specification)
Item
text
Amount of liquid consumed (per day)
Item
float
Amount of liquid consumed (specification)
Item
text
Diuresis (per day)
Item
float
Diuresis
Item
text
Hypertension: Mean systolic blood pressure
Item
integer
Hypertension: systolic
Item
text
Hypertension: Mean diastolic blood pressure
Item
integer
Hypertension: diastolic
Item
text
Hypertension: 24 h RR (syst/diast)
Item
text
Hypertension: Date of 24 h RR measurement
Item
date
Hypertension: Comments 24 h RR
Item
text
Fever
Item
boolean
Fever (specification)
Item
text
Stool
Item
boolean
Stool (specification)
Item
text
Micturition
Item
boolean
Micturition (specification)
Item
text
Nocturia
Item
boolean
Nocturia (specification)
Item
text
Coughing
Item
boolean
Coughing (specification)
Item
text
Sputum
Item
boolean
Sputum (specification)
Item
text
Shortness of breath
Item
boolean
Shortness of breath (specification)
Item
text
Edemata
Item
boolean
Edemata (specification)
Item
text
Night sweats
Item
boolean
Night sweats (specification)
Item
text
Joint trouble
Item
boolean
Joint trouble (specification)
Item
text
Signs of vasculitis
Item
boolean
Signs of vasculitis (specification)
Item
text
Appetite
Item
boolean
Appetite (specification)
Item
text
Sleep
Item
boolean
Sleep (specification)
Item
text
Nicotine
Item
boolean
Nicotine: packets per day
Item
float
Nicotine: duration of consumption (years)
Item
float
Nicotine: Ex-smoker
Item
boolean
Nicotine: Ex-smoker since (years)
Item
float
Nicotine (specification)
Item
text
Alcohol
Item
boolean
Alcohol (specification)
Item
text
Hypercholesterolemia
Item
boolean
Hypercholesterolemia (specification)
Item
text
Diabetes
Item
boolean
Diabetes (specification)
Item
text
Calcium/phosphate balance
Item
boolean
Calcium/phosphate balance (specification)
Item
text
Other risk factors
Item
boolean
Other risk factors (specification)
Item
text
General findings/skin
Item
boolean
General findings/skin (specification)
Item
text
Head
Item
boolean
Head (specification)
Item
text
Neck
Item
boolean
Neck (specification)
Item
text
Thorax
Item
boolean
Thorax (specification)
Item
text
Lungs
Item
boolean
Lungs (specification)
Item
text
Cardiovascular system
Item
boolean
Cardiovascular system (specification)
Item
text
Heart
Item
boolean
Heart (specification)
Item
text
Pulse status
Item
boolean
Pulse status (specification)
Item
text
Pulse status: Upper limb N.A.D.
Item
boolean
Pulse status: Right carotid artery
Item
text
Pulse status: Left carotid artery
Item
text
Pulse status: Right radial artery
Item
text
Pulse status: Left radial artery
Item
text
Pulse status: Lower limb N.A.D.
Item
boolean
Pulse status: Right femoral artery
Item
text
Pulse status: Left femoral artery
Item
text
Pulse status: Right popliteal artery
Item
text
Pulse status: Left popliteal artery
Item
text
Pulse status: Right posterior tibial artery
Item
text
Pulse status: Left posterior tibial artery
Item
text
Pulse status: Right dorsalis pedis artery
Item
text
Pulse status: Left dorsalis pedis artery
Item
text
Blood pressure right
Item
text
Blood pressure left
Item
text
Transplant
Item
boolean
Transplant (specification)
Item
text
Abdomen
Item
boolean
Abdomen (specification)
Item
text
Genitourinary system / rectum
Item
boolean
Genitourinary system / rectum (specification)
Item
text
Limbs/edema
Item
boolean
Limbs/edema (specification)
Item
text
Spine
Item
boolean
Spine (specification)
Item
text
Nervous system and psyche
Item
boolean
Nervous system and psyche (specification)
Item
text
Lymph nodes
Item
boolean
Lymph nodes (specification)
Item
text
Other
Item
boolean
Other (specification)
Item
text
Wound
Item
boolean
Wound (specification)
Item
text
Morphology (qualitative)
Item
text
Longitudinal diameter
Item
integer
Lateral diameter
Item
integer
Width of parenchyma
Item
integer
Doppler/Duplex sonography
Item
text
Resistive index
Item
text
Renal arteries Vmax
Item
integer
Quality of flow in renal artery
Item
text
Other
Item
text
Procedure
Item
text
Summary of medical history
Item
text
Summary of clinical examination
Item
text
Summary of sonography
Item
text
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