ID

191

Descripción

Form from HIS OpenVistA

Palabras clave

Versiones (2)
  1. 19/2/12 19/2/12 -
  2. 6/6/17 6/6/17 - Martin Dugas
Subido en

19 de febrero de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0
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HIS SHORT STAY RECORD-ORTHO SURGICARE

Alemán Inglés

HIS

1 formularios  
  1. StudyEvent: HIS
    1. HIS
Medical History
Descripción

Medical History

Chief complaint (CC)
Descripción

CHIEF COMPLAINT

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
History of present illness
Descripción

HISTORY OF PRESENT ILLNESS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Medical history
Descripción

Past Medical History

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Prior Surgery, History of (H/O) surgery, Past surgical history
Descripción

PRIOR SURGERIES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Hypersensitivity
Descripción

ALLERGY

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
current medication list
Descripción

CURRENT MEDICATIONS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1553892
HL7 V3 2006_05
CURMEDLIST
Review of systems
Descripción

REVIEW OF SYSTEMS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0489633
SNOMED CT 2011_0131
415300000
LOINC Version 232
MTHU001422
Family history (FH) of
Descripción

Family History

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
Social and personal history, Social and personal circumstances
Descripción

SOCIAL HISTORY (SH)

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
Immunisation
Descripción

IMMUNIZATIONS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0020971
SNOMED CT 2011_0131
127785005
MedDRA 14.1
10021431
Physical Examination
Descripción

Physical Examination

GENERAL APPEARANCE (normal: well developed, well nourished)
Descripción

GENERAL APPEARANCE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
Head, Ears, Eyes, Nose and Throat (HEENT)
Descripción

HEENT

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1512338
Neck (normal: Supple. No jugular vein distention)
Descripción

NECK

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Chest (normal: clear anteriorly and posteriorly)
Descripción

CHEST

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Breast (default: deferred)
Descripción

BREAST

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Heart (normal: Regular rate and rhythm without murmur)
Descripción

HEART

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0018787
SNOMED CT 2011_0131
80891009
LOINC Version 232
MTHU001067
Abdomen (normal: Soft, (+) Bowel sounds, Normal tone)
Descripción

ABDOMEN

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Lymph nodes (normal: not palpable)
Descripción

LYMPH NODES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0024204
SNOMED CT 2011_0131
59441001
LOINC Version 232
MTHU015050
Genitalia/Rectal (default: deferred)
Descripción

GENITALIA/RECTAL

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0017420, C0205052
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
Extremities, Limb structure
Descripción

EXTREMITIES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Skin (default: no abnormalities detected)
Descripción

SKIN

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
NEUROLOGICAL: intact
Descripción

NEUROLOGICAL: intact

Tipo de datos

boolean

Neurological assessment
Descripción

Neurological: intact except

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0027853
SNOMED CT 2011_0131
225398001
MedDRA 14.1
10050318
ICD-9-CM Version 2011
89.13
Diagnosis and Plan
Descripción

Diagnosis and Plan

ADMITTING DIAGNOSIS (AD)
Descripción

ADMITTING DIAGNOSIS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0332133
SNOMED CT 2011_0131
52870002
Planned
Descripción

PLAN: Surgery

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
ASA SCORE (1,2,3,4)
Descripción

ASA SCORE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
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Similar models

HIS

1 formularios
  1. StudyEvent: HIS
    1. HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Medical History
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
HISTORY OF PRESENT ILLNESS
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
Past Medical History
Item
Medical history
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
PRIOR SURGERIES
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
ALLERGY
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
CURRENT MEDICATIONS
Item
current medication list
string
C1553892 (UMLS CUI 2011AA)
CURMEDLIST (HL7 V3 2006_05)
REVIEW OF SYSTEMS
Item
Review of systems
string
C0489633 (UMLS CUI 2011AA)
415300000 (SNOMED CT 2011_0131)
MTHU001422 (LOINC Version 232)
Family History
Item
Family history (FH) of
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
SOCIAL HISTORY (SH)
Item
Social and personal history, Social and personal circumstances
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
IMMUNIZATIONS
Item
Immunisation
string
C0020971 (UMLS CUI 2011AA)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
Item Group
Physical Examination
GENERAL APPEARANCE
Item
GENERAL APPEARANCE (normal: well developed, well nourished)
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat (HEENT)
string
C1512338 (UMLS CUI 2011AA)
NECK
Item
Neck (normal: Supple. No jugular vein distention)
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Chest (normal: clear anteriorly and posteriorly)
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Breast (default: deferred)
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Heart (normal: Regular rate and rhythm without murmur)
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
ABDOMEN
Item
Abdomen (normal: Soft, (+) Bowel sounds, Normal tone)
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
LYMPH NODES
Item
Lymph nodes (normal: not palpable)
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
Genitalia/Rectal (default: deferred)
string
C0017420, C0205052 (UMLS CUI 2011AA)
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
EXTREMITIES
Item
Extremities, Limb structure
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Skin (default: no abnormalities detected)
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
NEUROLOGICAL: intact
Item
NEUROLOGICAL: intact
boolean
Neurological: intact except
Item
Neurological assessment
string
C0027853 (UMLS CUI 2011AA)
225398001 (SNOMED CT 2011_0131)
10050318 (MedDRA 14.1)
89.13 (ICD-9-CM Version 2011)
Item Group
Diagnosis and Plan
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Surgery
Item
Planned
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
ASA SCORE
Item
ASA SCORE (1,2,3,4)
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
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