ID

22528

Description

Form from HIS OpenVistA

Keywords

Versions (2)
  1. 2/19/12 2/19/12 -
  2. 6/6/17 6/6/17 - Martin Dugas
Uploaded on

June 6, 2017

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

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
Medical History
Description

Medical History

Alias
UMLS CUI-1
C0262926
Chief complaint (CC)
Description

CHIEF COMPLAINT

Data type

string

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

HISTORY OF PRESENT ILLNESS

Data type

string

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

Past Medical History

Data type

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
Description

PRIOR SURGERIES

Data type

string

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

ALLERGY

Data type

string

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

CURRENT MEDICATIONS

Data type

string

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

REVIEW OF SYSTEMS

Data type

string

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

Family History

Data type

string

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

SOCIAL HISTORY (SH)

Data type

string

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

IMMUNIZATIONS

Data type

string

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

Physical Examination

Alias
UMLS CUI-1
C0031809
GENERAL APPEARANCE (normal: well developed, well nourished)
Description

GENERAL APPEARANCE

Data type

string

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

HEENT

Data type

string

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

NECK

Data type

string

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

CHEST

Data type

string

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

BREAST

Data type

string

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

HEART

Data type

string

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

ABDOMEN

Data type

string

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

LYMPH NODES

Data type

string

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

GENITALIA/RECTAL

Data type

text

Alias
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
UMLS CUI [1,1]
C0017420
UMLS CUI [1,2]
C0205052
Extremities, Limb structure
Description

EXTREMITIES

Data type

string

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

SKIN

Data type

string

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

Neurological examination normal

Data type

boolean

Alias
UMLS CUI [1,1]
C0027853
UMLS CUI [1,2]
C0205307
Neurological: intact except
Description

Neurological assessment

Data type

text

Alias
SNOMED CT 2011_0131
225398001
MedDRA 14.1
10050318
ICD-9-CM Version 2011
89.13
UMLS CUI [1]
C0027853
Diagnosis and Plan
Description

Diagnosis and Plan

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0599880
ADMITTING DIAGNOSIS (AD)
Description

ADMITTING DIAGNOSIS

Data type

string

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

PLAN: Surgery

Data type

string

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
ASA SCORE
Description

ASA SCORE

Data type

integer

Alias
SNOMED CT 2011_0131
413347006
UMLS CUI [1]
C1531480
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Similar models

HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Medical History
C0262926 (UMLS CUI-1)
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
C0031809 (UMLS CUI-1)
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)
text
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI [1,1])
C0205052 (UMLS CUI [1,2])
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 examination normal
Item
NEUROLOGICAL: intact
boolean
C0027853 (UMLS CUI [1,1])
C0205307 (UMLS CUI [1,2])
Neurological assessment
Item
Neurological: intact except
text
225398001 (SNOMED CT 2011_0131)
10050318 (MedDRA 14.1)
89.13 (ICD-9-CM Version 2011)
C0027853 (UMLS CUI [1])
Item Group
Diagnosis and Plan
C0011900 (UMLS CUI-1)
C0599880 (UMLS CUI-2)
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)
Item
ASA SCORE
integer
413347006 (SNOMED CT 2011_0131)
C1531480 (UMLS CUI [1])
ASA SCORE
Code List
ASA SCORE
CL Item
ASA 1 (1)
CL Item
ASA 2 (2)
CL Item
ASA 3 (3)
CL Item
ASA 4 (4)
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