ID

18679

Beskrivning

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

Nyckelord

  1. 2016-11-15 2016-11-15 -
  2. 2016-11-30 2016-11-30 -
Uppladdad den

15 november 2016

DOI

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Licens

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

General information
Beskrivning

General information

Examiner
Beskrivning

Examiner

Datatyp

text

Date of medical history taking
Beskrivning

Date of medical history taking

Datatyp

date

Mode of medical history taking
Beskrivning

Mode of medical history taking

Datatyp

text

Current medical history
Beskrivning

Current medical history

Datatyp

text

Vegetative anamnesis and management of risk factors
Beskrivning

Vegetative anamnesis and management of risk factors

Height
Beskrivning

Height

Datatyp

float

Måttenheter
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Weight
Beskrivning

Weight

Datatyp

float

Måttenheter
  • kg
Alias
UMLS CUI [1]
C0005910
kg
BMI
Beskrivning

BMI

Datatyp

text

Change in weight
Beskrivning

Change in weight

Datatyp

boolean

Change in weight (specification)
Beskrivning

Change in weight (specification)

Datatyp

text

Amount of liquid consumed (per day)
Beskrivning

Amount of liquid consumed (per day)

Datatyp

float

Måttenheter
  • l
l
Amount of liquid consumed (specification)
Beskrivning

Amount of liquid consumed (specification)

Datatyp

text

Diuresis (per day)
Beskrivning

Diuresis (per day)

Datatyp

float

Måttenheter
  • l
l
Diuresis
Beskrivning

Diuresis

Datatyp

text

Hypertension: Mean systolic blood pressure
Beskrivning

Hypertension: Mean systolic blood pressure

Datatyp

integer

Hypertension: systolic
Beskrivning

Hypertension: systolic

Datatyp

text

Hypertension: Mean diastolic blood pressure
Beskrivning

Hypertension: Mean diastolic blood pressure

Datatyp

integer

Hypertension: diastolic
Beskrivning

Hypertension: diastolic

Datatyp

text

Hypertension: 24 h RR (syst/diast)
Beskrivning

Hypertension: 24 h RR (syst/diast)

Datatyp

text

Hypertension: Date of 24 h RR measurement
Beskrivning

Hypertension: Date of 24 h RR measurement

Datatyp

date

Hypertension: Comments 24 h RR
Beskrivning

Hypertension: Comments 24 h RR

Datatyp

text

Fever
Beskrivning

Fever

Datatyp

boolean

Fever (specification)
Beskrivning

Fever (specification)

Datatyp

text

Stool
Beskrivning

Stool

Datatyp

boolean

Stool (specification)
Beskrivning

Stool (specification)

Datatyp

text

Micturition
Beskrivning

Micturition

Datatyp

boolean

Micturition (specification)
Beskrivning

Micturition (specification)

Datatyp

text

Nocturia
Beskrivning

Nocturia

Datatyp

boolean

Nocturia (specification)
Beskrivning

Nocturia (specification)

Datatyp

text

Coughing
Beskrivning

Coughing

Datatyp

boolean

Coughing (specification)
Beskrivning

Coughing (specification)

Datatyp

text

Sputum
Beskrivning

Sputum

Datatyp

boolean

Sputum (specification)
Beskrivning

Sputum (specification)

Datatyp

text

Shortness of breath
Beskrivning

Shortness of breath

Datatyp

boolean

Shortness of breath (specification)
Beskrivning

Shortness of breath (specification)

Datatyp

text

Edemata
Beskrivning

Edemata

Datatyp

boolean

Edemata (specification)
Beskrivning

Edemata (specification)

Datatyp

text

Night sweats
Beskrivning

Night sweats

Datatyp

boolean

Night sweats (specification)
Beskrivning

Night sweats (specification)

Datatyp

text

Joint trouble
Beskrivning

Joint trouble

Datatyp

boolean

Joint trouble (specification)
Beskrivning

Joint trouble (specification)

Datatyp

text

Signs of vasculitis
Beskrivning

Signs of vasculitis

Datatyp

boolean

Signs of vasculitis (specification)
Beskrivning

Signs of vasculitis (specification)

Datatyp

text

Appetite
Beskrivning

Appetite

Datatyp

boolean

Appetite (specification)
Beskrivning

Appetite (specification)

Datatyp

text

Sleep
Beskrivning

Sleep

Datatyp

boolean

Sleep (specification)
Beskrivning

Sleep (specification)

Datatyp

text

Nicotine
Beskrivning

Nicotine

Datatyp

boolean

Nicotine: packets per day
Beskrivning

Nicotine: packets per day

Datatyp

float

Nicotine: duration of consumption (years)
Beskrivning

Nicotine: duration of consumption (years)

Datatyp

float

Måttenheter
  • years
years
Nicotine: Ex-smoker
Beskrivning

Nicotine: Ex-smoker

Datatyp

boolean

Nicotine: Ex-smoker since (years)
Beskrivning

Nicotine: Ex-smoker since (years)

Datatyp

float

Måttenheter
  • years
years
Nicotine (specification)
Beskrivning

Nicotine (specification)

Datatyp

text

Alcohol
Beskrivning

Alcohol

Datatyp

boolean

Alcohol (specification)
Beskrivning

Alcohol (specification)

Datatyp

text

Hypercholesterolemia
Beskrivning

Hypercholesterolemia

Datatyp

boolean

Hypercholesterolemia (specification)
Beskrivning

Hypercholesterolemia (specification)

Datatyp

text

Diabetes
Beskrivning

Diabetes

Datatyp

boolean

Diabetes (specification)
Beskrivning

Diabetes (specification)

Datatyp

text

Calcium/phosphate balance
Beskrivning

Calcium/phosphate balance

Datatyp

boolean

Calcium/phosphate balance (specification)
Beskrivning

Calcium/phosphate balance (specification)

Datatyp

text

Other risk factors
Beskrivning

Other risk factors

Datatyp

boolean

Other risk factors (specification)
Beskrivning

Other risk factors (specification)

Datatyp

text

Clinical examination
Beskrivning

Clinical examination

General findings/skin
Beskrivning

General findings/skin

Datatyp

boolean

General findings/skin (specification)
Beskrivning

General findings/skin (specification)

Datatyp

text

Head
Beskrivning

Head

Datatyp

boolean

Head (specification)
Beskrivning

Head (specification)

Datatyp

text

Neck
Beskrivning

Neck

Datatyp

boolean

Neck (specification)
Beskrivning

Neck (specification)

Datatyp

text

Thorax
Beskrivning

Thorax

Datatyp

boolean

Thorax (specification)
Beskrivning

Thorax (specification)

Datatyp

text

Lungs
Beskrivning

Lungs

Datatyp

boolean

Lungs (specification)
Beskrivning

Lungs (specification)

Datatyp

text

Cardiovascular system
Beskrivning

Cardiovascular system

Datatyp

boolean

Cardiovascular system (specification)
Beskrivning

Cardiovascular system (specification)

Datatyp

text

Heart
Beskrivning

Heart

Datatyp

boolean

Heart (specification)
Beskrivning

Heart (specification)

Datatyp

text

Pulse status
Beskrivning

Pulse status

Datatyp

boolean

Pulse status (specification)
Beskrivning

Pulse status (specification)

Datatyp

text

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

Pulse status: Upper limb N.A.D.

Datatyp

boolean

Pulse status: Right carotid artery
Beskrivning

Pulse status: Right carotid artery

Datatyp

text

Pulse status: Left carotid artery
Beskrivning

Pulse status: Left carotid artery

Datatyp

text

Pulse status: Right radial artery
Beskrivning

Pulse status: Right radial artery

Datatyp

text

Pulse status: Left radial artery
Beskrivning

Pulse status: Left radial artery

Datatyp

text

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

Pulse status: Lower limb N.A.D.

Datatyp

boolean

Pulse status: Right femoral artery
Beskrivning

Pulse status: Right femoral artery

Datatyp

text

Pulse status: Left femoral artery
Beskrivning

Pulse status: Left femoral artery

Datatyp

text

Pulse status: Right popliteal artery
Beskrivning

Pulse status: Right popliteal artery

Datatyp

text

Pulse status: Left popliteal artery
Beskrivning

Pulse status: Left popliteal artery

Datatyp

text

Pulse status: Right posterior tibial artery
Beskrivning

Pulse status: Right posterior tibial artery

Datatyp

text

Pulse status: Left posterior tibial artery
Beskrivning

Pulse status: Left posterior tibial artery

Datatyp

text

Pulse status: Right dorsalis pedis artery
Beskrivning

Pulse status: Right dorsalis pedis artery

Datatyp

text

Pulse status: Left dorsalis pedis artery
Beskrivning

Pulse status: Left dorsalis pedis artery

Datatyp

text

Blood pressure right
Beskrivning

Blood pressure right

Datatyp

text

Måttenheter
  • mmHg
mmHg
Blood pressure left
Beskrivning

Blood pressure left

Datatyp

text

Måttenheter
  • mmHg
mmHg
Transplant
Beskrivning

Transplant

Datatyp

boolean

Transplant (specification)
Beskrivning

Transplant (specification)

Datatyp

text

Abdomen
Beskrivning

Abdomen

Datatyp

boolean

Abdomen (specification)
Beskrivning

Abdomen (specification)

Datatyp

text

Genitourinary system / rectum
Beskrivning

Genitourinary system / rectum

Datatyp

boolean

Genitourinary system / rectum (specification)
Beskrivning

Genitourinary system / rectum (specification)

Datatyp

text

Limbs/edema
Beskrivning

Limbs/edema

Datatyp

boolean

Limbs/edema (specification)
Beskrivning

Limbs/edema (specification)

Datatyp

text

Spine
Beskrivning

Spine

Datatyp

boolean

Spine (specification)
Beskrivning

Spine (specification)

Datatyp

text

Nervous system and psyche
Beskrivning

Nervous system and psyche

Datatyp

boolean

Nervous system and psyche (specification)
Beskrivning

Nervous system and psyche (specification)

Datatyp

text

Lymph nodes
Beskrivning

Lymph nodes

Datatyp

boolean

Lymph nodes (specification)
Beskrivning

Lymph nodes (specification)

Datatyp

text

Other
Beskrivning

Other

Datatyp

boolean

Other (specification)
Beskrivning

Other (specification)

Datatyp

text

Wound
Beskrivning

Wound

Datatyp

boolean

Wound (specification)
Beskrivning

Wound (specification)

Datatyp

text

Sonography of transplanted kidney
Beskrivning

Sonography of transplanted kidney

Morphology (qualitative)
Beskrivning

Morphology (qualitative)

Datatyp

text

Longitudinal diameter
Beskrivning

Longitudinal diameter

Datatyp

integer

Måttenheter
  • mm
mm
Lateral diameter
Beskrivning

Lateral diameter

Datatyp

integer

Måttenheter
  • mm
mm
Width of parenchyma
Beskrivning

Width of parenchyma

Datatyp

integer

Måttenheter
  • mm
mm
Doppler/Duplex sonography
Beskrivning

Doppler/Duplex sonography

Datatyp

text

Resistive index
Beskrivning

Resistive index

Datatyp

text

Renal arteries Vmax
Beskrivning

Renal arteries Vmax

Datatyp

integer

Måttenheter
  • cm/s
cm/s
Quality of flow in renal artery
Beskrivning

Quality of flow in renal artery

Datatyp

text

Other
Beskrivning

Other

Datatyp

text

Summary/Procedure
Beskrivning

Summary/Procedure

Procedure
Beskrivning

Procedure

Datatyp

text

Summary of medical history
Beskrivning

Summary of medical history

Datatyp

text

Summary of clinical examination
Beskrivning

Summary of clinical examination

Datatyp

text

Summary of sonography
Beskrivning

Summary of sonography

Datatyp

text

Similar models

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

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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