Informações:
Falhas:
ID
22528
Descrição
Form from HIS OpenVistA
Palavras-chave
Versões (2)
- 19/02/2012 19/02/2012 -
- 06/06/2017 06/06/2017 - Martin Dugas
Transferido a
6 de junho de 2017
DOI
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Licença
Creative Commons BY-NC 3.0
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SHORT STAY RECORD-ORTHO SURGICARE
Similar models
HIS
- StudyEvent: HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
HISTORY OF PRESENT ILLNESS
Item
History of present illness
string
Past Medical History
Item
Medical history
string
PRIOR SURGERIES
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
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)
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)
CURMEDLIST (HL7 V3 2006_05)
REVIEW OF SYSTEMS
Item
Review of systems
string
Family History
Item
Family history (FH) of
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
57177007 (SNOMED CT 2011_0131)
SOCIAL HISTORY (SH)
Item
Social and personal history, Social and personal circumstances
string
IMMUNIZATIONS
Item
Immunisation
string
C0020971 (UMLS CUI 2011AA)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
GENERAL APPEARANCE
Item
GENERAL APPEARANCE (normal: well developed, well nourished)
string
HEENT
Item
Head, Ears, Eyes, Nose and Throat (HEENT)
string
C1512338 (UMLS CUI 2011AA)
NECK
Item
Neck (normal: Supple. No jugular vein distention)
string
CHEST
Item
Chest (normal: clear anteriorly and posteriorly)
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Breast (default: deferred)
string
HEART
Item
Heart (normal: Regular rate and rhythm without murmur)
string
ABDOMEN
Item
Abdomen (normal: Soft, (+) Bowel sounds, Normal tone)
string
LYMPH NODES
Item
Lymph nodes (normal: not palpable)
string
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])
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI [1,1])
C0205052 (UMLS CUI [1,2])
EXTREMITIES
Item
Extremities, Limb structure
string
SKIN
Item
Skin (default: no abnormalities detected)
string
Neurological examination normal
Item
NEUROLOGICAL: intact
boolean
C0027853 (UMLS CUI [1,1])
C0205307 (UMLS CUI [1,2])
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])
10050318 (MedDRA 14.1)
89.13 (ICD-9-CM Version 2011)
C0027853 (UMLS CUI [1])
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
52870002 (SNOMED CT 2011_0131)
PLAN: Surgery
Item
Planned
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
397943006 (SNOMED CT 2011_0131)
CL Item
ASA 1 (1)
CL Item
ASA 2 (2)
CL Item
ASA 3 (3)
CL Item
ASA 4 (4)