ID

18679

Beschreibung

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

Stichworte

  1. 15.11.16 15.11.16 -
  2. 30.11.16 30.11.16 -
Hochgeladen am

15. November 2016

DOI

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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

General information
Beschreibung

General information

Examiner
Beschreibung

Examiner

Datentyp

text

Date of medical history taking
Beschreibung

Date of medical history taking

Datentyp

date

Mode of medical history taking
Beschreibung

Mode of medical history taking

Datentyp

text

Current medical history
Beschreibung

Current medical history

Datentyp

text

Vegetative anamnesis and management of risk factors
Beschreibung

Vegetative anamnesis and management of risk factors

Height
Beschreibung

Height

Datentyp

float

Maßeinheiten
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Weight
Beschreibung

Weight

Datentyp

float

Maßeinheiten
  • kg
Alias
UMLS CUI [1]
C0005910
kg
BMI
Beschreibung

BMI

Datentyp

text

Change in weight
Beschreibung

Change in weight

Datentyp

boolean

Change in weight (specification)
Beschreibung

Change in weight (specification)

Datentyp

text

Amount of liquid consumed (per day)
Beschreibung

Amount of liquid consumed (per day)

Datentyp

float

Maßeinheiten
  • l
l
Amount of liquid consumed (specification)
Beschreibung

Amount of liquid consumed (specification)

Datentyp

text

Diuresis (per day)
Beschreibung

Diuresis (per day)

Datentyp

float

Maßeinheiten
  • l
l
Diuresis
Beschreibung

Diuresis

Datentyp

text

Hypertension: Mean systolic blood pressure
Beschreibung

Hypertension: Mean systolic blood pressure

Datentyp

integer

Hypertension: systolic
Beschreibung

Hypertension: systolic

Datentyp

text

Hypertension: Mean diastolic blood pressure
Beschreibung

Hypertension: Mean diastolic blood pressure

Datentyp

integer

Hypertension: diastolic
Beschreibung

Hypertension: diastolic

Datentyp

text

Hypertension: 24 h RR (syst/diast)
Beschreibung

Hypertension: 24 h RR (syst/diast)

Datentyp

text

Hypertension: Date of 24 h RR measurement
Beschreibung

Hypertension: Date of 24 h RR measurement

Datentyp

date

Hypertension: Comments 24 h RR
Beschreibung

Hypertension: Comments 24 h RR

Datentyp

text

Fever
Beschreibung

Fever

Datentyp

boolean

Fever (specification)
Beschreibung

Fever (specification)

Datentyp

text

Stool
Beschreibung

Stool

Datentyp

boolean

Stool (specification)
Beschreibung

Stool (specification)

Datentyp

text

Micturition
Beschreibung

Micturition

Datentyp

boolean

Micturition (specification)
Beschreibung

Micturition (specification)

Datentyp

text

Nocturia
Beschreibung

Nocturia

Datentyp

boolean

Nocturia (specification)
Beschreibung

Nocturia (specification)

Datentyp

text

Coughing
Beschreibung

Coughing

Datentyp

boolean

Coughing (specification)
Beschreibung

Coughing (specification)

Datentyp

text

Sputum
Beschreibung

Sputum

Datentyp

boolean

Sputum (specification)
Beschreibung

Sputum (specification)

Datentyp

text

Shortness of breath
Beschreibung

Shortness of breath

Datentyp

boolean

Shortness of breath (specification)
Beschreibung

Shortness of breath (specification)

Datentyp

text

Edemata
Beschreibung

Edemata

Datentyp

boolean

Edemata (specification)
Beschreibung

Edemata (specification)

Datentyp

text

Night sweats
Beschreibung

Night sweats

Datentyp

boolean

Night sweats (specification)
Beschreibung

Night sweats (specification)

Datentyp

text

Joint trouble
Beschreibung

Joint trouble

Datentyp

boolean

Joint trouble (specification)
Beschreibung

Joint trouble (specification)

Datentyp

text

Signs of vasculitis
Beschreibung

Signs of vasculitis

Datentyp

boolean

Signs of vasculitis (specification)
Beschreibung

Signs of vasculitis (specification)

Datentyp

text

Appetite
Beschreibung

Appetite

Datentyp

boolean

Appetite (specification)
Beschreibung

Appetite (specification)

Datentyp

text

Sleep
Beschreibung

Sleep

Datentyp

boolean

Sleep (specification)
Beschreibung

Sleep (specification)

Datentyp

text

Nicotine
Beschreibung

Nicotine

Datentyp

boolean

Nicotine: packets per day
Beschreibung

Nicotine: packets per day

Datentyp

float

Nicotine: duration of consumption (years)
Beschreibung

Nicotine: duration of consumption (years)

Datentyp

float

Maßeinheiten
  • years
years
Nicotine: Ex-smoker
Beschreibung

Nicotine: Ex-smoker

Datentyp

boolean

Nicotine: Ex-smoker since (years)
Beschreibung

Nicotine: Ex-smoker since (years)

Datentyp

float

Maßeinheiten
  • years
years
Nicotine (specification)
Beschreibung

Nicotine (specification)

Datentyp

text

Alcohol
Beschreibung

Alcohol

Datentyp

boolean

Alcohol (specification)
Beschreibung

Alcohol (specification)

Datentyp

text

Hypercholesterolemia
Beschreibung

Hypercholesterolemia

Datentyp

boolean

Hypercholesterolemia (specification)
Beschreibung

Hypercholesterolemia (specification)

Datentyp

text

Diabetes
Beschreibung

Diabetes

Datentyp

boolean

Diabetes (specification)
Beschreibung

Diabetes (specification)

Datentyp

text

Calcium/phosphate balance
Beschreibung

Calcium/phosphate balance

Datentyp

boolean

Calcium/phosphate balance (specification)
Beschreibung

Calcium/phosphate balance (specification)

Datentyp

text

Other risk factors
Beschreibung

Other risk factors

Datentyp

boolean

Other risk factors (specification)
Beschreibung

Other risk factors (specification)

Datentyp

text

Clinical examination
Beschreibung

Clinical examination

General findings/skin
Beschreibung

General findings/skin

Datentyp

boolean

General findings/skin (specification)
Beschreibung

General findings/skin (specification)

Datentyp

text

Head
Beschreibung

Head

Datentyp

boolean

Head (specification)
Beschreibung

Head (specification)

Datentyp

text

Neck
Beschreibung

Neck

Datentyp

boolean

Neck (specification)
Beschreibung

Neck (specification)

Datentyp

text

Thorax
Beschreibung

Thorax

Datentyp

boolean

Thorax (specification)
Beschreibung

Thorax (specification)

Datentyp

text

Lungs
Beschreibung

Lungs

Datentyp

boolean

Lungs (specification)
Beschreibung

Lungs (specification)

Datentyp

text

Cardiovascular system
Beschreibung

Cardiovascular system

Datentyp

boolean

Cardiovascular system (specification)
Beschreibung

Cardiovascular system (specification)

Datentyp

text

Heart
Beschreibung

Heart

Datentyp

boolean

Heart (specification)
Beschreibung

Heart (specification)

Datentyp

text

Pulse status
Beschreibung

Pulse status

Datentyp

boolean

Pulse status (specification)
Beschreibung

Pulse status (specification)

Datentyp

text

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

Pulse status: Upper limb N.A.D.

Datentyp

boolean

Pulse status: Right carotid artery
Beschreibung

Pulse status: Right carotid artery

Datentyp

text

Pulse status: Left carotid artery
Beschreibung

Pulse status: Left carotid artery

Datentyp

text

Pulse status: Right radial artery
Beschreibung

Pulse status: Right radial artery

Datentyp

text

Pulse status: Left radial artery
Beschreibung

Pulse status: Left radial artery

Datentyp

text

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

Pulse status: Lower limb N.A.D.

Datentyp

boolean

Pulse status: Right femoral artery
Beschreibung

Pulse status: Right femoral artery

Datentyp

text

Pulse status: Left femoral artery
Beschreibung

Pulse status: Left femoral artery

Datentyp

text

Pulse status: Right popliteal artery
Beschreibung

Pulse status: Right popliteal artery

Datentyp

text

Pulse status: Left popliteal artery
Beschreibung

Pulse status: Left popliteal artery

Datentyp

text

Pulse status: Right posterior tibial artery
Beschreibung

Pulse status: Right posterior tibial artery

Datentyp

text

Pulse status: Left posterior tibial artery
Beschreibung

Pulse status: Left posterior tibial artery

Datentyp

text

Pulse status: Right dorsalis pedis artery
Beschreibung

Pulse status: Right dorsalis pedis artery

Datentyp

text

Pulse status: Left dorsalis pedis artery
Beschreibung

Pulse status: Left dorsalis pedis artery

Datentyp

text

Blood pressure right
Beschreibung

Blood pressure right

Datentyp

text

Maßeinheiten
  • mmHg
mmHg
Blood pressure left
Beschreibung

Blood pressure left

Datentyp

text

Maßeinheiten
  • mmHg
mmHg
Transplant
Beschreibung

Transplant

Datentyp

boolean

Transplant (specification)
Beschreibung

Transplant (specification)

Datentyp

text

Abdomen
Beschreibung

Abdomen

Datentyp

boolean

Abdomen (specification)
Beschreibung

Abdomen (specification)

Datentyp

text

Genitourinary system / rectum
Beschreibung

Genitourinary system / rectum

Datentyp

boolean

Genitourinary system / rectum (specification)
Beschreibung

Genitourinary system / rectum (specification)

Datentyp

text

Limbs/edema
Beschreibung

Limbs/edema

Datentyp

boolean

Limbs/edema (specification)
Beschreibung

Limbs/edema (specification)

Datentyp

text

Spine
Beschreibung

Spine

Datentyp

boolean

Spine (specification)
Beschreibung

Spine (specification)

Datentyp

text

Nervous system and psyche
Beschreibung

Nervous system and psyche

Datentyp

boolean

Nervous system and psyche (specification)
Beschreibung

Nervous system and psyche (specification)

Datentyp

text

Lymph nodes
Beschreibung

Lymph nodes

Datentyp

boolean

Lymph nodes (specification)
Beschreibung

Lymph nodes (specification)

Datentyp

text

Other
Beschreibung

Other

Datentyp

boolean

Other (specification)
Beschreibung

Other (specification)

Datentyp

text

Wound
Beschreibung

Wound

Datentyp

boolean

Wound (specification)
Beschreibung

Wound (specification)

Datentyp

text

Sonography of transplanted kidney
Beschreibung

Sonography of transplanted kidney

Morphology (qualitative)
Beschreibung

Morphology (qualitative)

Datentyp

text

Longitudinal diameter
Beschreibung

Longitudinal diameter

Datentyp

integer

Maßeinheiten
  • mm
mm
Lateral diameter
Beschreibung

Lateral diameter

Datentyp

integer

Maßeinheiten
  • mm
mm
Width of parenchyma
Beschreibung

Width of parenchyma

Datentyp

integer

Maßeinheiten
  • mm
mm
Doppler/Duplex sonography
Beschreibung

Doppler/Duplex sonography

Datentyp

text

Resistive index
Beschreibung

Resistive index

Datentyp

text

Renal arteries Vmax
Beschreibung

Renal arteries Vmax

Datentyp

integer

Maßeinheiten
  • cm/s
cm/s
Quality of flow in renal artery
Beschreibung

Quality of flow in renal artery

Datentyp

text

Other
Beschreibung

Other

Datentyp

text

Summary/Procedure
Beschreibung

Summary/Procedure

Procedure
Beschreibung

Procedure

Datentyp

text

Summary of medical history
Beschreibung

Summary of medical history

Datentyp

text

Summary of clinical examination
Beschreibung

Summary of clinical examination

Datentyp

text

Summary of sonography
Beschreibung

Summary of sonography

Datentyp

text

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

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