ID

214

Beskrivning

Form from HIS OpenVistA

Nyckelord

  1. 2012-02-25 2012-02-25 -
  2. 2017-06-07 2017-06-07 - Martin Dugas
Uppladdad den

25 februari 2012

DOI

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Creative Commons BY-NC 3.0

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HIS SHORT STAY RECORD-PAIN MANAGEMENT

  1. StudyEvent: HIS
    1. HIS
SHORT STAY RECORD-PAIN MANAGEMENT
Beskrivning

SHORT STAY RECORD-PAIN MANAGEMENT

Hauptbeschwerden
Beskrivning

CHIEF COMPLAINT

Datatyp

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
Anamnese der aktuellen Erkrankung
Beskrivning

HISTORY OF PRESENT ILLNESS

Datatyp

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Anamnese
Beskrivning

PAST MEDICAL HISTORY

Datatyp

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Frühere Operationen
Beskrivning

PRIOR SURGERIES

Datatyp

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Allergie
Beskrivning

ALLERGIES

Datatyp

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
aktuelle Medikation
Beskrivning

CURRENT MEDICATIONS

Datatyp

string

Alias
UMLS CUI 2011AA
C1553892
Anamnese der Organsysteme
Beskrivning

REVIEW OF SYSTEMS

Datatyp

string

Alias
UMLS CUI 2011AA
C0489633
SNOMED CT 2011_0131
415300000
LOINC Version 232
MTHU001422
Familienanamnese
Beskrivning

FAMILY HISTORY

Datatyp

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
Sozialanamnese
Beskrivning

SOCIAL HISTORY

Datatyp

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
Physical Exam
Beskrivning

Physical Exam

Allgemeinzustand
Beskrivning

GENERAL APPEARANCE

Datatyp

string

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
Head, Ears, Eyes, Nose and Throat
Beskrivning

HEENT

Datatyp

string

Alias
UMLS CUI 2011AA
C1512338
Hals
Beskrivning

NECK

Datatyp

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Thorax
Beskrivning

CHEST

Datatyp

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Brust
Beskrivning

BREAST

Datatyp

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Herz
Beskrivning

HEART

Datatyp

string

Alias
UMLS CUI 2011AA
C0018787
SNOMED CT 2011_0131
80891009
LOINC Version 232
MTHU001067
Abdomen
Beskrivning

ABDOMEN

Datatyp

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Lymphknoten
Beskrivning

LYMPH NODES

Datatyp

string

Alias
UMLS CUI 2011AA
C0024204
SNOMED CT 2011_0131
59441001
LOINC Version 232
MTHU015050
GENITALIA/RECTAL
Beskrivning

GENITALIA/RECTAL

Datatyp

string

Alias
UMLS CUI 2011AA
C0017420, C0205052
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
Extremitäten
Beskrivning

EXTREMITIES

Datatyp

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Haut
Beskrivning

SKIN

Datatyp

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Nervensystem
Beskrivning

NEUROLOGICAL

Datatyp

string

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
Aufnahmediagnose
Beskrivning

ADMITTING DIAGNOSIS

Datatyp

string

Alias
UMLS CUI 2011AA
C0332133
SNOMED CT 2011_0131
52870002
PLAN: Surgery
Beskrivning

PLAN: Surgery

Datatyp

boolean

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
ASA Status
Beskrivning

ASA SCORE

Datatyp

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
CHIEF COMPLAINT
Item
Hauptbeschwerden
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
HISTORY OF PRESENT ILLNESS
Item
Anamnese der aktuellen Erkrankung
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
PAST MEDICAL HISTORY
Item
Anamnese
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
PRIOR SURGERIES
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
ALLERGIES
Item
Allergie
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
CURRENT MEDICATIONS
Item
aktuelle Medikation
string
C1553892 (UMLS CUI 2011AA)
REVIEW OF SYSTEMS
Item
Anamnese der Organsysteme
string
C0489633 (UMLS CUI 2011AA)
415300000 (SNOMED CT 2011_0131)
MTHU001422 (LOINC Version 232)
FAMILY HISTORY
Item
Familienanamnese
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
SOCIAL HISTORY
Item
Sozialanamnese
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
Item Group
GENERAL APPEARANCE
Item
Allgemeinzustand
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat
string
C1512338 (UMLS CUI 2011AA)
NECK
Item
Hals
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Brust
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Herz
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
ABDOMEN
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
LYMPH NODES
Item
Lymphknoten
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
GENITALIA/RECTAL
string
C0017420, C0205052 (UMLS CUI 2011AA)
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
EXTREMITIES
Item
Extremitäten
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Haut
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
NEUROLOGICAL
Item
Nervensystem
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
ADMITTING DIAGNOSIS
Item
Aufnahmediagnose
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Surgery
Item
PLAN: Surgery
boolean
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
ASA SCORE
Item
ASA Status
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)

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