ID

22528

Beskrivning

Form from HIS OpenVistA

Nyckelord

  1. 2012-02-19 2012-02-19 -
  2. 2017-06-06 2017-06-06 - Martin Dugas
Uppladdad den

6 juni 2017

DOI

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Creative Commons BY-NC 3.0

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    SHORT STAY RECORD-ORTHO SURGICARE

    1. StudyEvent: HIS
      1. HIS
    Medical History
    Beskrivning

    Medical History

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

    CHIEF COMPLAINT

    Datatyp

    string

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

    HISTORY OF PRESENT ILLNESS

    Datatyp

    string

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

    Past Medical History

    Datatyp

    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
    Beskrivning

    PRIOR SURGERIES

    Datatyp

    string

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

    ALLERGY

    Datatyp

    string

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

    CURRENT MEDICATIONS

    Datatyp

    string

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

    REVIEW OF SYSTEMS

    Datatyp

    string

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

    Family History

    Datatyp

    string

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

    SOCIAL HISTORY (SH)

    Datatyp

    string

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

    IMMUNIZATIONS

    Datatyp

    string

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

    Physical Examination

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

    GENERAL APPEARANCE

    Datatyp

    string

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

    HEENT

    Datatyp

    string

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

    NECK

    Datatyp

    string

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

    CHEST

    Datatyp

    string

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

    BREAST

    Datatyp

    string

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

    HEART

    Datatyp

    string

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

    ABDOMEN

    Datatyp

    string

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

    LYMPH NODES

    Datatyp

    string

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

    GENITALIA/RECTAL

    Datatyp

    text

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

    EXTREMITIES

    Datatyp

    string

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

    SKIN

    Datatyp

    string

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

    Neurological examination normal

    Datatyp

    boolean

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

    Neurological assessment

    Datatyp

    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
    Beskrivning

    Diagnosis and Plan

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

    ADMITTING DIAGNOSIS

    Datatyp

    string

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

    PLAN: Surgery

    Datatyp

    string

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

    ASA SCORE

    Datatyp

    integer

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

    Similar models

    1. StudyEvent: HIS
      1. HIS
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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])
    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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