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22558
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Form from HIS OpenVista
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- 09-03-12 09-03-12 -
- 08-06-17 08-06-17 - Martin Dugas
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8 juni 2017
DOI
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Creative Commons BY-NC 3.0
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NURSING ASSESSMENT (adult)
Similar models
HIS
- StudyEvent: HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
initial assessment
Item
see initial Admission Assessment
boolean
C0150637 (UMLS CUI [1])
assessment date
Item
DONE ON
date
C2985720 (UMLS CUI [1])
ADMISSION
Item
ADMISSION TEXT
text
C0030673 (UMLS CUI [1])
postoperative day
Item
POST OP DAY
integer
C0032790 (UMLS CUI [1])
Neurological examination normal
Item
Normal Baseline: Alert, responsive to stimuli, sensation intact, speech clear and appropriate, PERRLA, hand grips equal, can follow directions, oriented X4, cooperative with treatment plan, hygiene and grooming adequate, maintains eye contact, poses no danger to self or to others, normal affect.
boolean
C1112287 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
CL Item
Spontaneously (4)
C2012046 (UMLS CUI-1)
CL Item
To speech (3)
C2012048 (UMLS CUI-1)
CL Item
To pain (2)
C2012047 (UMLS CUI-1)
CL Item
None (1)
C2012045 (UMLS CUI-1)
CL Item
Oriented (5)
C2012059 (UMLS CUI-1)
CL Item
Confused (4)
C2012056 (UMLS CUI-1)
CL Item
Inappropriate words (3)
C2012058 (UMLS CUI-1)
CL Item
Incomprehensible words (2)
C2012057 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
CL Item
Obeys command (6)
C2012055 (UMLS CUI-1)
CL Item
Localize to pain (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws (4)
C2012052 (UMLS CUI-1)
CL Item
Flexion to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Extension to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE
Item
GLASCOW COMA SCALE SCORE ADULT
integer
C1271007 (UMLS CUI [1])
Right Pupil Size
Item
Right Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Left Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,2])
ORIENTATION
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
43173001 (SNOMED CT 2011_0131)
History of SEIZURE ACTIVITY
Item
HX OF SEIZURE ACTIVITY
text
C1148156 (UMLS CUI [1])
AFFECT
Item
Affekt
string
C0001721 (UMLS CUI 2011AA)
4065008 (SNOMED CT 2011_0131)
4065008 (SNOMED CT 2011_0131)
SPEECH
Item
Sprache
string
NUMBNESS OR TINGLING
Item
NUMBNESS OR TINGLING PRESENT
text
C3842982 (UMLS CUI [1])
Cardiovascular system normal
Item
NORMAL BASELINE: Regular rate and rhythm, no edema, capillary refill less than 3 seconds, rate: 60-100 per minute, BP normotensive.
boolean
C0577867 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Antithromboembolic stockings
Item
TEDS ON
boolean
C0419312 (UMLS CUI [1])
Vascular Sequential Compression Devices
Item
SCDS ON
boolean
C0180062 (UMLS CUI [1])
HEART SOUNDS
Item
Herztöne
string
C0018820 (UMLS CUI 2011AA)
23472005 (SNOMED CT 2011_0131)
23472005 (SNOMED CT 2011_0131)
Radial pulse (L/R)
Item
Radial pulse (L/R)
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pedal pulse
Item
Pedal pulse (L/R)
text
C0232157 (UMLS CUI [1])
Pos-Tibial Pulse (L/R)
Item
Tibialis posterior-Puls (L/R)
string
C1720310 (UMLS CUI 2011AA)
421568004 (SNOMED CT 2011_0131)
421568004 (SNOMED CT 2011_0131)
Popliteal Pulse (L/R)
Item
Popliteal-Puls (L/R)
string
C0232151 (UMLS CUI 2011AA)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
Brachial Pulse (L/R)
Item
Brachialis-Puls (L/R)
string
C1096531 (UMLS CUI 2011AA)
10053929 (MedDRA 14.1)
10053929 (MedDRA 14.1)
Carotid Pulse (L/R)
Item
Karotis-Puls (L/R)
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
10053926 (MedDRA 14.1)
AV SHUNT
Item
AV SHUNT/GRAFT
text
C1456474 (UMLS CUI [1])
BRUIT
Item
BRUIT
text
C0006318 (UMLS CUI [1])
SHUNT BRUIT
Item
SHUNT/GRAFT BRUITS
text
C0232112 (UMLS CUI [1])
THRILL
Item
THRILL PALPATED
text
C2678517 (UMLS CUI [1])
CAPILLARY REFILL
Item
CAPILLARY REFILL
text
C0425716 (UMLS CUI [1])
NAIL BED COLOR
Item
NAIL BED COLOR
text
C0574757 (UMLS CUI [1])
Edema
Item
Ödem
string
C0013604 (UMLS CUI 2011AA)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
Heart RHYTHM
Item
Heart RHYTHM
text
C0232187 (UMLS CUI [1])
PACEMAKER PRESENT
Item
(künstlicher) Herzschrittmacher
boolean
NORMAL BASELINE EYES
Item
Normal Baseline EYES: Without drainage, sclera white.
boolean
Normal Baseline Ears
Item
Normal Baseline EARS: No complaint of pain.
boolean
Normal Baseline Nose
Item
Normal Baseline NOSE: No drainage or congestion.
boolean
Normal Baseline Throat
Item
Normal Baseline THROAT: No complaint of pain.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Pupil Right Size [mm]
Item
Pupil Right Size [mm]
integer
Pupil Right Reaction
Item
Pupil Right Reaction
string
Pupil Left Size [mm]
Item
Pupil Left Size [mm]
integer
Pupil Left Reaction
Item
Pupil Left Reaction
string
Eye Complains
Item
Eye Complains
string
Right Sclera
Item
Right Sclera
string
Left Sclera
Item
Left Sclera
string
Drainage
Item
Drainage
boolean
Drainage Color
Item
Drainage Color
string
EARS(EXTERNAL CANAL)
Item
EARS(EXTERNAL CANAL)
string
C/O Pain
Item
C/O Pain
boolean
Tempanic Membranes
Item
Trommelfell
string
Tubes
Item
Tubes
string
Hard of Hearing
Item
Hard of Hearing
boolean
Hearing Loss
Item
Hearing Loss
boolean
Deafness
Item
Deafness
boolean
CL Item
RT (1)
CL Item
LT (2)
CL Item
bilateral (3)
Patent
Item
Patent
boolean
Dizziness
Item
Schwindel
boolean
C0012833 (UMLS CUI 2011AA)
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
Tinnitus
Item
Tinnitus
boolean
C0040264 (UMLS CUI 2011AA)
60862001 (SNOMED CT 2011_0131)
10043882 (MedDRA 14.1)
H93.1 (ICD-10-CM Version 2010)
388.3 (ICD-9-CM Version 2011)
E10287 (CTCAE 1105E)
60862001 (SNOMED CT 2011_0131)
10043882 (MedDRA 14.1)
H93.1 (ICD-10-CM Version 2010)
388.3 (ICD-9-CM Version 2011)
E10287 (CTCAE 1105E)
Drainage
Item
Drainage
boolean
Color of Ear Drainage
Item
Color of Ear Drainage
string
Nares patent
Item
Nares patent
boolean
Nares Drainage
Item
Nares Drainage
boolean
Septum
Item
Nasenseptum
string
Throat Pain
Item
Sore throat, Pain in throat, Pharyngeal pain
boolean
C0242429 (UMLS CUI 2011AA)
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
Mouth Sores
Item
Mouth Sores
boolean
Appearance of Throat
Item
Appearance of Throat
string
Mucous Membranes
Item
Mucous Membranes
string
NORMAL BASELINE
Item
Normal Baseline: Regular, unlabored, symmetrical, no accessory muscles used, no abnormal breathsounds, rate 12-20 per minute.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
BREATH SOUNDS
Item
Atemgeräusch
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
RESPIRATORY EFFORT
Item
RESPIRATORY EFFORT
string
CL Item
symmetrical (1)
CL Item
non-symmetrical (2)
INCENTIVE SPIROMETRY DONE
Item
INCENTIVE SPIROMETRY DONE
boolean
OXYGEN DELIVERY METHOD
Item
OXYGEN DELIVERY METHOD
string
Pulse Oximeter present with alarms set
Item
Pulse Oximeter present with alarms set
boolean
Cardio-Respriratory Monitor present with alarms set
Item
Cardio-Respriratory Monitor present with alarms set
boolean
COUGH TYPE
Item
Husten
string
C0010200 (UMLS CUI 2011AA)
49727002 (SNOMED CT 2011_0131)
10011224 (MedDRA 14.1)
R05 (ICD-10-CM Version 2010)
786.2 (ICD-9-CM Version 2011)
E13364 (CTCAE 1105E)
49727002 (SNOMED CT 2011_0131)
10011224 (MedDRA 14.1)
R05 (ICD-10-CM Version 2010)
786.2 (ICD-9-CM Version 2011)
E13364 (CTCAE 1105E)
Sputum (incl. Quantity)
Item
Sputum
string
C0038056 (UMLS CUI 2011AA)
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
CHEST TUBE PRESENT
Item
CHEST TUBE PRESENT
boolean
CHEST TUBE LOCATION
Item
CHEST TUBE LOCATION
boolean
Chest Tube Suction Setting
Item
Chest Tube Suction Setting
string
CL Item
none (1)
CL Item
small (2)
CL Item
moderate (3)
CL Item
large (4)
NORMAL BASELINE GI
Item
Normal Baseline GI: Abdomen soft, non-distended, bowel tones present X4, continent, stool soft, brown and formed, states regular bowel movements.
boolean
Last BM
Item
Last Bowel Movement
date
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
ABDOMINAL DESCRIPTION
Item
Abdomen
string
BOWEL SOUNDS
Item
Darmgeräusche
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
FLATUS
Item
FLATUS
boolean
GASTRIC SYMPTOMS
Item
GASTRIC SYMPTOMS
string
NARES
Item
NARES
string
NG TUBE TYPE
Item
Nasogastric Tube Type
string
NG placement checked
Item
NG placement checked
boolean
Suction Setting
Item
Suction Setting
string
Gastric Content Color
Item
Gastric Content Color
string
NGT irrigated
Item
NGT irrigated (with # ML's of #)
string
OSTOMY TYPE
Item
OSTOMY TYPE
string
RECTAL BAG PRESENT
Item
RECTAL BAG PRESENT
boolean
NORMAL BASELINE
Item
Normal Baseline Genitourinary: Voids without pain, burning, or hesitation, urine clear, no strong odor, no distention, continent.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Item
Geschlecht
string
CL Item
Male (1)
CL Item
Female (2)
INCONTINENT
Item
INCONTINENT
boolean
VOIDS SUFFICIENT QUANITY
Item
VOIDS SUFFICIENT QUANITY
boolean
IS PATIENT RECEIVING DIALYSIS
Item
IS PATIENT RECEIVING DIALYSIS
boolean
ODOR PRESENT
Item
ODOR PRESENT
boolean
URINE COLOR
Item
URINE COLOR
string
CATHETER PRESENT
Item
Katheter
boolean
C0085590 (UMLS CUI 2011AA)
19923001 (SNOMED CT 2011_0131)
19923001 (SNOMED CT 2011_0131)
CATHETER SIZE
Item
Katheter-Größe
string
C0449963 (UMLS CUI 2011AA)
260967009 (SNOMED CT 2011_0131)
260967009 (SNOMED CT 2011_0131)
Date of insertion
Item
Date of insertion
date
Urine color
Item
Urine color
string
URINARY SYMPTOMS
Item
URINARY SYMPTOMS
string
SEXUALLY ACTIVE
Item
SEXUALLY ACTIVE
boolean
CURRENTLY ON MENSES
Item
CURRENTLY ON MENSES
boolean
DISCHARGE PRESENT
Item
Ausfluss
boolean
C0012621 (UMLS CUI 2011AA)
75823008 (SNOMED CT 2011_0131)
75823008 (SNOMED CT 2011_0131)
Discharge color
Item
Discharge color
string
Discharge odor
Item
Discharge odor
string
Discharge consistency
Item
Discharge consistency
string
ABNORMAL GENITALIA DESCRIPTION
Item
ABNORMAL GENITALIA DESCRIPTION
string
NORMAL BASELINE
Item
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, long bones intact, gait steady.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
GENERALIZED WEAKNESS
Item
GENERALIZED WEAKNESS
boolean
LIMITED ROM
Item
LIMITED ROM
boolean
LIMITED MOBILITY
Item
LIMITED MOBILITY
boolean
CONTRACTURES
Item
CONTRACTURES
boolean
FRACTURE(S) LOCATION
Item
FRACTURE(S) LOCATION
string
FINGER DIGITS
Item
FINGER DIGITS
string
TOE DIGITS
Item
TOE DIGITS
string
PARALYSIS TYPE
Item
PARALYSIS TYPE
string
CL Item
left (1)
CL Item
right (2)
LEFT UPPER EXTREMITIES
Item
LEFT UPPER EXTREMITIES
string
RIGHT UPPER EXTREMITIES
Item
RIGHT UPPER EXTREMITIES
string
GRIPS EQUAL
Item
GRIPS EQUAL
boolean
LEFT LOWER EXTREMITIES
Item
LEFT LOWER EXTREMITIES
string
RIGHT LOWER EXTREMITIES
Item
RIGHT LOWER EXTREMITIES
string
UNSTEADY GAIT
Item
UNSTEADY GAIT
boolean
NORMAL BASELINE
Item
NORMAL BASELINE: Warm, dry, turgor elastic, pink undertone to skin or mucosa, no lesions, skin smooth and intact, moist mucous membranes.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
SKIN COLOR
Item
SKIN COLOR
string
TEMPERATURE
Item
Temperatur
string
MOIST
Item
MOIST
boolean
SKIN TURGOR
Item
SKIN TURGOR
string
RASH LOCATION
Item
RASH LOCATION
string
RASH DESCRIPTION
Item
RASH DESCRIPTION
string
TATTOO'S/PIERCINGS
Item
TATTOO'S/PIERCINGS
string
SKIN TEARS, LOCATION/ Description
Item
SKIN TEARS, LOCATION/ Description
string
Bony Prominences Assessed
Item
Bony Prominences Assessed
boolean
At risk for skin breakdown
Item
At risk for skin breakdown
boolean
Braden Score 18 or less
Item
Braden Score 18 or less
boolean
Pressure ulcer(s) present
Item
Pressure ulcer(s) present
boolean
ULCER #
Item
ULCER #
string
Ulcer LOCATION
Item
Ulcer LOCATION
string
ULCER STAGE
Item
ULCER STAGE
string
Ulcer Length
Item
Ulcer Length
string
Ulcer Width
Item
Ulcer Width
string
Ulcer Depth
Item
Ulcer Depth
string
WOUND #
Item
Wunde
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
Wound healed
Item
Wound healed
boolean
Wound Location
Item
Wound Location
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
Length (cm, mm)
Item
Length (cm, mm)
string
Width (cm, mm)
Item
Width (cm, mm)
string
Depth (cm, mm)
Item
Depth (cm, mm)
string
Undermining
Item
Undermining
boolean
Tunneling
Item
Tunneling
boolean
Surrounding Skin
Item
Surrounding Skin
string
Wound Base
Item
Wound Base
string
Exudate
Item
Exsudat
string
Exudate Color
Item
Exudate Color
string
Sensation
Item
Sensation
string
Odor: Before Cleaning
Item
Odor: Before Cleaning
boolean
Odor: After Cleaning
Item
Odor: After Cleaning
boolean
Cleansed with/irrigated with
Item
Cleansed with/irrigated with
string
Hemostasis Achieved with
Item
Hemostasis Achieved with
string
Wound Medication Applied
Item
Wound Medication Applied
string
Wound Filled with
Item
Wound Filled with
string
Wound covered with
Item
Wound covered with
string
Wound secured with
Item
Wound secured with
string
Wound Pressure Relief
Item
Wound Pressure Relief
string
Comments
Item
Comments
string
Photograph Date
Item
Photograph Date
date
Incision #:
Item
Inzision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
34896006 (SNOMED CT 2011_0131)
MID WOUND#
Item
MID WOUND#
string
Site
Item
Site
string
Closure Type
Item
Closure Type
string
Incision Appearance
Item
Incision Appearance
string
Dressing Changed
Item
Dressing Changed
boolean
Date Dressing Changed
Item
Date Dressing Changed
date
Dressing Type
Item
Dressing Type
string
Dressing Appearance
Item
Dressing Appearance
string
Drains
Item
Drainage
string
Current Diet
Item
Diät
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
41829006 (SNOMED CT 2011_0131)
FEEDING TUBE PRESENT
Item
Ernährung über Sonde
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula: # strength @ # cc's/hour via kangaroo pump
string
RESIDUALS CHECKED
Item
RESIDUALS CHECKED: AMOUNT # CC
string
NPO
Item
NPO
boolean
BREAKFAST
Item
BREAKFAST
string
Breakfast: Amount taken
Item
Breakfast: Amount taken
string
Breakfast: Patient fed by
Item
Breakfast: Patient fed by
string
LUNCH
Item
LUNCH
string
Lunch: Amount taken
Item
Lunch: Amount taken
string
Lunch: Patient fed by
Item
Lunch: Patient fed by
string
SUPPER
Item
SUPPER
string
Supper: Amount taken
Item
Supper: Amount taken
string
Supper: Patient fed by
Item
Supper: Patient fed by
string
Supper: Amount taken
Item
Supper: Amount taken
string
NARRATIVE: IV Therapy
Item
NARRATIVE: IV Therapy
string
IV HEPLOCKED
Item
IV HEPLOCKED
boolean
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
IV DISCONTINUED
Item
IV DISCONTINUED
boolean
CATHETER INTACT
Item
CATHETER INTACT
boolean
IV Catheter Size
Item
IV Catheter Size
string
IV Site Location
Item
IV Site Location
string
CENTRAL LINE PORT
Item
Zentralvenöser Katheter (ZVK)
string
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
52124006 (SNOMED CT 2011_0131)
IV FLUIDS
Item
Infusion
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
Left to count:
Item
Left to count:
string
IV Fluid Rate: @ ml/hr
Item
IV Fluid Rate: @ ml/hr
integer
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Item
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
string
PCA PUMP: at @ cc's/hr
Item
PCA PUMP: at @ cc's/hr
string
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
INSERTION DATE
Item
INSERTION DATE
date
DRESSING CHANGE DUE
Item
DRESSING CHANGE DUE
date
SITE CHANGE DUE
Item
SITE CHANGE DUE
date
PLACED ON IMED
Item
PLACED ON IMED
boolean
SIDE RAILS UP
Item
SIDE RAILS UP
boolean
IN LOW POSTION
Item
IN LOW POSTION
boolean
BED/CRIB
Item
BED/CRIB
string
CALL BELL WITHIN REACH
Item
CALL BELL WITHIN REACH
boolean
ALLERGY BAND ON
Item
ALLERGY BAND ON
boolean
NAME BAND ON
Item
NAME BAND ON
boolean
BLOOD BAND ON
Item
BLOOD BAND ON
boolean
BED SAFETY
Item
BED SAFETY
string
Unable to assess fall risk status at this time due to patient is:
Item
Unable to assess fall risk status at this time due to patient is:
string
Confusion/Disorientation/Impulsivity +4
Item
Confusion/Disorientation/Impulsivity +4
boolean
Symptomatic Depression +2
Item
Symptomatic Depression +2
boolean
Altered Elimination +1
Item
Altered Elimination +1
boolean
Dizziness/Vertigo +1
Item
Dizziness/Vertigo +1
boolean
Gender (male) +1
Item
Gender (male) +1
boolean
Any Administered Antiepileptics (Anticonvulsants) +2
Item
Any Administered Antiepileptics (Anticonvulsants) +2
boolean
Any Administered Benzodiazepines +1
Item
Any Administered Benzodiazepines +1
boolean
CL Item
Ability to rise in single movement-No loss of balance with steps +0 (Ability to rise in single movement-No loss of balance with steps +0)
CL Item
Pushes up, successful in one attempt +1 (Pushes up, successful in one attempt +1)
CL Item
Multiple attempts but successful +3 (Multiple attempts but successful +3)
CL Item
Unable to rise without assistance during test (OR if a medical order states the same and/or complete bed rest is ordered) +4 (Unable to rise without assistance during test (OR if a medical order states the same and/or complete bed rest is ordered) +4)
FINAL Hendrich II RISK SCORE
Item
FINAL Hendrich II RISK SCORE
integer
Assist with Ambulation
Item
Assist with Ambulation
boolean
Reorient Q2H or Less
Item
Reorient Q2H or Less
boolean
Gait Belt
Item
Gait Belt
boolean
ID Patient at Risk
Item
ID Patient at Risk
boolean
Restraints (see policy)
Item
Restraints (see policy)
boolean
Multi-personnel Transfer
Item
Multi-personnel Transfer
boolean
Close Observation
Item
Close Observation
boolean
Non-slip Footwear
Item
Non-slip Footwear
boolean
Bed in lowest position
Item
Bed in lowest position
boolean
Lock wheels of vehicles of conveyance during transfer
Item
Lock wheels of vehicles of conveyance during transfer
boolean
Upper siderails raised
Item
Upper siderails raised
boolean
Call light in reach
Item
Call light in reach
boolean
Assist with ambulation
Item
Assist with ambulation
boolean
Offer toileting at least every 2 hours
Item
Offer toileting at least every 2 hours
boolean
Offer fluid/nutrition every 2 hours
Item
Offer fluid/nutrition every 2 hours
boolean
Place frequently used objects within reach
Item
Place frequently used objects within reach
boolean
Provide adequate lighting
Item
Provide adequate lighting
boolean
Provide sensory impairment/orientation devices (clocks,etc)
Item
Provide sensory impairment/orientation devices (clocks,etc)
boolean
Provide adequate rest periods
Item
Provide adequate rest periods
boolean
Use age appropriate distractions for confusion/disorientation
Item
Use age appropriate distractions for confusion/disorientation
boolean
Remove harmful hazards
Item
Remove harmful hazards
boolean
Provide appropriate and least restrictive patient supervision/surveillance
Item
Provide appropriate and least restrictive patient supervision/surveillance
boolean
Communicate information about fall risk to caregivers
Item
Communicate information about fall risk to caregivers
boolean
Encourage family/support system to participate in care
Item
Encourage family/support system to participate in care
boolean
Teach/educate family/support system Fall Prevention information
Item
Teach/educate family/support system Fall Prevention information
boolean
Implement Fall Prevention Protocol for Hendrich II Score>5
Item
Implement Fall Prevention Protocol for Hendrich II Score>5
boolean
Implement Universal Fall Prevention Intervention
Item
Implement Universal Fall Prevention Intervention
boolean
Monitor transfers to/from bed/chair(etc.)
Item
Monitor transfers to/from bed/chair(etc.)
boolean
Use appropriate assistance for transfers to/from bed/chair
Item
Use appropriate assistance for transfers to/from bed/chair
boolean
Use chairs with armrests and of proper height for transfers
Item
Use chairs with armrests and of proper height for transfers
boolean
Implement progressive ambulation(unless contraindicated by condition/orders)
Item
Implement progressive ambulation(unless contraindicated by condition/orders)
boolean
Encourage/Provide self-care assistance
Item
Encourage/Provide self-care assistance
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Provide assistive devices for ambulation (canes/walkers/etc.)
Item
Provide assistive devices for ambulation (canes/walkers/etc.)
boolean
Gait Belt during transport/ambulation
Item
Gait Belt during transport/ambulation
boolean
Teach patient/family to call for help and WAIT for help before
Item
Teach patient/family to call for help and WAIT for help before
boolean
attempting any transfer/ambulation
Item
attempting any transfer/ambulation
boolean
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Assist with post-elimination hygiene
Item
Assist with post-elimination hygiene
boolean
Remove non-essential clothing
Item
Remove non-essential clothing
boolean
Instruct patient on importance of toileting when offered by staff
Item
Instruct patient on importance of toileting when offered by staff
boolean
Monitor for 'patient's normal' bladder/bowel habits
Item
Monitor for 'patient's normal' bladder/bowel habits
boolean
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Item
Monitor for causes of incontinence (diuretics,cathartics,etc.)
boolean
Monitor skin integrity
Item
Monitor skin integrity
boolean
Item Group
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Monitor drug dosages
Item
Monitor drug dosages
boolean
Evaluate sensory functions
Item
Evaluate sensory functions
boolean
Monitor/Assess for drug overdose
Item
Monitor/Assess for drug overdose
boolean
Monitor response to exercise
Item
Monitor response to exercise
boolean
Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
Item
Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
boolean
UNIVERSAL FALL PRECAUTIONS
Item
UNIVERSAL FALL PRECAUTIONS
boolean
Neutropenic Precautions taken.
Item
Neutropenic Precautions taken.
boolean
Date of last chemotherapy cycle
Item
Date of last chemotherapy cycle
date
Chemotherapy Agent/Dosage
Item
Chemotherapy Agent/Dosage
string
day of chemotherapy
Item
day of chemotherapy
integer
Chemotherapy ADVERSE EFFECTS
Item
Chemotherapy ADVERSE EFFECTS
string
Radiation Safety Precautions taken.
Item
Radiation Safety Precautions taken.
boolean
RADIATION INTERNAL
Item
RADIATION INTERNAL
string
Radiation External: Location of Markings
Item
Radiation External: Location of Markings
string
Radiation: Number of Fractions prescribed
Item
Radiation: Number of Fractions prescribed
string
Remaining Radiations
Item
Remaining Radiations
string
Radiation Adverse Effects
Item
Radiation Adverse Effects
string
AFFECTED SITE
Item
AFFECTED SITE
string
CIRCULATORY STATUS
Item
CIRCULATORY STATUS
string
SKIN COLOR
Item
SKIN COLOR
string
SENSATION
Item
Sensation
string
MOVEMENT
Item
MOVEMENT
string
TEMPERATURE
Item
Temperatur
string
SKIN CONDITION
Item
Hautzustand
string
PULSE(s) SITE(s)
Item
PULSE(s) SITE(s)
string
RESPONSE
Item
RESPONSE
string
POSITION OF LIMB
Item
POSITION OF LIMB
string
ORTHOPEDIC DEVICE IN USE
Item
ORTHOPEDIC DEVICE IN USE
string
CONTINUOUS PASSIVE MOTION
Item
CONTINUOUS PASSIVE MOTION
string
POUNDS
Item
POUNDS
string
CERVICAL COLLARS
Item
CERVICAL COLLARS
string
AFO BRACE: Foot/Feet
Item
AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
string
SWELLING
Item
SWELLING
string
PIN SITES
Item
PIN SITES
string
CLEANED WITH
Item
CLEANED WITH
string
NARRATIVE
Item
NARRATIVE
string
Gravida
Item
Gravida
integer
Para
Item
Para
integer
EDC
Item
EDC
date
Weeks gestation
Item
Weeks gestation
integer
Fetal movement
Item
Fetal movement
boolean
FHR
Item
FHR
string
Vision
Item
Vision
string
Headaches
Item
Kopfschmerzen
boolean
C0018681 (UMLS CUI 2011AA)
25064002 (SNOMED CT 2011_0131)
10019211 (MedDRA 14.1)
MTHU020860 (LOINC Version 232)
R51 (ICD-10-CM Version 2010)
784.0 (ICD-9-CM Version 2011)
E12678 (CTCAE 1105E)
25064002 (SNOMED CT 2011_0131)
10019211 (MedDRA 14.1)
MTHU020860 (LOINC Version 232)
R51 (ICD-10-CM Version 2010)
784.0 (ICD-9-CM Version 2011)
E12678 (CTCAE 1105E)
Abdominal Cramps
Item
Abdominal Cramps
boolean
Uterine Contraction
Item
Uterine Contraction
boolean
Epigastric Pain
Item
Epigastric Pain
boolean
Vaginal Discharge
Item
Vaginal Discharge
boolean
Additional Findings
Item
Additional Findings
string
Fundal Height
Item
Fundal Height
integer
NARRATIVE: Antepartum
Item
NARRATIVE: Antepartum
string
Fundal Location
Item
Fundal Location
string
LOCHIA
Item
LOCHIA
string
Perineum
Item
Perineum
string
BREASTS
Item
Brust
string
NIPPLES
Item
Mamillen
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
24142002 (SNOMED CT 2011_0131)
Mother/Baby Relationship
Item
Mother/Baby Relationship
string
BONDING
Item
BONDING
string
Feedings
Item
Feedings
string
Hemorrhoids
Item
Hämorrhoiden
string
C0019112 (UMLS CUI 2011AA)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
NARRATIVE: Post partum
Item
NARRATIVE: Post partum
string
General Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
273688003 (SNOMED CT 2011_0131)
Vaginal Packing
Item
Vaginal Packing
string
Equipment/Devices
Item
Equipment/Devices
string
EQUIPMENT/DEVICES
Item
EQUIPMENT/DEVICES
string
Item
Prepared for treatment/procedure as soon as possible.
string
Code List
Prepared for treatment/procedure as soon as possible.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
not applicable (4)
Item
Provided detailed information about events/procedures/treatments.
string
Code List
Provided detailed information about events/procedures/treatments.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Item
Involved in decision process regarding pain control/medication/care decisions
string
Code List
Involved in decision process regarding pain control/medication/care decisions
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Confusion/Disorientation +3
Item
Confusion/Disorientation +3
boolean
Depression +4
Item
Depression +4
boolean
C0011581 (UMLS CUI 2011AA)
35489007 (SNOMED CT 2011_0131)
10012401 (MedDRA 14.1)
F32.9 (ICD-10-CM Version 2010)
35489007 (SNOMED CT 2011_0131)
10012401 (MedDRA 14.1)
F32.9 (ICD-10-CM Version 2010)
Altered Elimination (incontinence, nocturia) +3
Item
Altered Elimination (incontinence, nocturia) +3
boolean
Non-Adaptive Mobility/Generalized Weakness +2
Item
Non-Adaptive Mobility/Generalized Weakness +2
boolean
Dizziness/Vertigo +3
Item
Dizziness/Vertigo +3
boolean
Primary Cancer Diagnosis +3
Item
Primary Cancer Diagnosis +3
boolean
C0006826 (UMLS CUI 2011AA)
363346000 (SNOMED CT 2011_0131)
10028997 (MedDRA 14.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)
363346000 (SNOMED CT 2011_0131)
10028997 (MedDRA 14.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)
RECENT HISTORY of FALLS +7
Item
RECENT HISTORY of FALLS +7
boolean
FINAL Hendrich Fall RISK SCORE
Item
FINAL Hendrich Fall RISK SCORE
integer
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)