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ID
18679
Beschreibung
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: AN MS MEDD Anamnese KU NTX.
Stichworte
Versionen (2)
- 15.11.16 15.11.16 -
- 30.11.16 30.11.16 -
Hochgeladen am
15. November 2016
DOI
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Creative Commons BY-NC 3.0
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AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform
AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform
Ähnliche Modelle
AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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