ID

22606

Descripción

Form from HIS OpenVista

Palabras clave

  1. 9/3/12 9/3/12 -
  2. 8/6/17 8/6/17 - Martin Dugas
  3. 20/9/21 20/9/21 -
Subido en

8 de junio de 2017

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0

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NURSING ASSESSMENT (pedi)

  1. StudyEvent: HIS
    1. HIS
Child Nursing Assessment
Descripción

Child Nursing Assessment

Alias
UMLS CUI-1
C0028680
UMLS CUI-2
C0008059
see initial Admission Assessment
Descripción

initial Assessment

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0150637
DONE ON
Descripción

assessment date

Tipo de datos

date

Alias
UMLS CUI [1]
C2985720
ADMISSION TEXT
Descripción

ADMISSION

Tipo de datos

text

Alias
UMLS CUI [1]
C0030673
POST OP DAY
Descripción

POST OP DAY

Tipo de datos

integer

Alias
UMLS CUI [1]
C0032790
Neuro / Psychosocial
Descripción

Neuro / Psychosocial

Alias
UMLS CUI-1
C0027853
Normal Baseline: Alert, appropriate verbalization, response appropriate for age, pupils equal and reactive, sensation intact.
Descripción

Neurological examination normal

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1112287
Narrative: Abnormal Findings
Descripción

Abnormal Findings

Tipo de datos

text

Alias
UMLS CUI [1]
C1704258
GLASGOW COMA SCALE ADULT
Descripción

GLASGOW COMA SCALE ADULT

Alias
UMLS CUI-1
C1271007
EYES OPEN
Descripción

Eyes open

Tipo de datos

integer

Alias
UMLS CUI [1]
C3648956
BEST VERBAL RESPONSE
Descripción

BEST VERBAL RESPONSE

Tipo de datos

integer

Alias
UMLS CUI [1]
C3648957
BEST MOTOR RESPONSE
Descripción

BEST MOTOR RESPONSE

Tipo de datos

integer

Alias
UMLS CUI [1]
C3648958
GLASCOW COMA SCALE SCORE ADULT
Descripción

GLASCOW COMA SCALE SCORE

Tipo de datos

integer

Alias
UMLS CUI [1]
C1271007
Pupillen
Descripción

Pupillen

Alias
UMLS CUI-1
C0034121
Right Size [mm]
Descripción

Right Pupil Size

Tipo de datos

integer

Unidades de medida
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205090
mm
Right Reaction
Descripción

Right Pupil Reaction

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
Left Size [mm]
Descripción

Left Pupil Size

Tipo de datos

integer

Unidades de medida
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205091
mm
Left Reaction
Descripción

Left Pupil Reaction

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
GLASGOW COMA SCALE CHILD
Descripción

GLASGOW COMA SCALE CHILD

Alias
UMLS CUI-1
C0017594
UMLS CUI-2
C0008059
EYES OPEN
Descripción

EYES OPEN

Tipo de datos

integer

Alias
UMLS CUI [1]
C3648956
BEST VERBAL RESPONSE
Descripción

BEST VERBAL RESPONSE

Tipo de datos

integer

BEST MOTOR RESPONSE
Descripción

BEST MOTOR RESPONSE

Tipo de datos

integer

Alias
UMLS CUI [1]
C3648958
GLASCOW COMA SCALE SCORE CHILD
Descripción

GLASCOW COMA SCALE SCORE CHILD

Tipo de datos

integer

ORIENTATION
Descripción

ORIENTATION

Alias
UMLS CUI-1
C0029266
Orientierung
Descripción

ORIENTATION

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
HX OF SEIZURE ACTIVITY
Descripción

History of SEIZURE ACTIVITY

Tipo de datos

text

Alias
UMLS CUI [1]
C1148156
Affekt
Descripción

AFFECT

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0001721
SNOMED CT 2011_0131
4065008
Sprache
Descripción

SPEECH

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0037817
SNOMED CT 2011_0131
87335007
LOINC Version 232
MTHU021528
NUMBNESS OR TINGLING PRESENT
Descripción

NUMBNESS OR TINGLING

Tipo de datos

text

Alias
UMLS CUI [1]
C3842982
Kardiovaskuläres System
Descripción

Kardiovaskuläres System

Alias
UMLS CUI-1
C0007226
Normal Baseline: Regular rate and rhythm, no edema, capillary refill less than 2 seconds, pink nailbeds, warm extemities, peripheral pulses strong and regular.
Descripción

Cardiovascular System Normal

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0577867
Narrative: Abnormal Findings
Descripción

Abnormal Findings

Tipo de datos

text

Alias
UMLS CUI [1]
C1704258
TEDS ON
Descripción

Antithromboembolic stockings

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0419312
SCDS ON
Descripción

Vascular Sequential Compression Devices

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0180062
Herztöne
Descripción

HEART SOUNDS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0018820
SNOMED CT 2011_0131
23472005
Radial pulse (L/R)
Descripción

Radial pulse (L/R)

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0232142
SNOMED CT 2011_0131
65452004
MedDRA 14.1
10053935
Pedal pulse (L/R)
Descripción

Pedal pulse

Tipo de datos

text

Alias
UMLS CUI [1]
C0232157
Tibialis posterior-Puls (L/R)
Descripción

Pos-Tibial Pulse

Tipo de datos

text

Alias
SNOMED CT 2011_0131
421568004
UMLS CUI [1]
C1720310
Popliteal-Puls (L/R)
Descripción

Popliteal Pulse (L/R)

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0232151
SNOMED CT 2011_0131
74828005
MedDRA 14.1
10053938
Brachialis-Puls (L/R)
Descripción

Brachial Pulse (L/R)

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1096531
MedDRA 14.1
10053929
Karotis-Puls (L/R)
Descripción

Carotid Pulse (L/R)

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1096529
MedDRA 14.1
10053926
AV SHUNT/GRAFT
Descripción

AV SHUNT

Tipo de datos

text

Alias
UMLS CUI [1]
C1456474
SHUNT/GRAFT LOCATION
Descripción

SHUNT LOCATION

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1442858
UMLS CUI [1,2]
C0450429
BRUIT
Descripción

BRUIT

Tipo de datos

text

Alias
UMLS CUI [1]
C0006318
SHUNT/GRAFT BRUITS
Descripción

SHUNT BRUIT

Tipo de datos

text

Alias
UMLS CUI [1]
C0232112
THRILL PALPATED
Descripción

THRILL

Tipo de datos

text

Alias
UMLS CUI [1]
C2678517
CAPILLARY REFILL
Descripción

CAPILLARY REFILL

Tipo de datos

text

Alias
UMLS CUI [1]
C0425716
NAIL BED COLOR
Descripción

NAIL BED COLOR

Tipo de datos

text

Alias
UMLS CUI [1]
C0574757
Ödem
Descripción

Edema

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0013604
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
Heart RHYTHM
Descripción

Heart RHYTHM

Tipo de datos

text

Alias
UMLS CUI [1]
C0232187
(künstlicher) Herzschrittmacher
Descripción

PACEMAKER PRESENT

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0030163
SNOMED CT 2011_0131
14106009
LOINC Version 232
MTHU024521
Eyes Ear Nose & Throat
Descripción

Eyes Ear Nose & Throat

Alias
UMLS CUI-1
C3494720
Normal Baseline EYES: Without drainage, sclera white.
Descripción

EYES NORMAL

Tipo de datos

boolean

Alias
UMLS CUI [1]
C4230579
Normal Baseline EARS: No complaint of pain.
Descripción

Normal Ears

Tipo de datos

boolean

Alias
UMLS CUI [1]
C4230157
Normal Baseline NOSE: No drainage or congestion.
Descripción

Normal Nose

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0577884
Normal Baseline THROAT: No complaint of pain.
Descripción

Normal Throat

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0577002
NARRATIVE: Abnormal Findings
Descripción

Abnormal Findings

Tipo de datos

text

Alias
UMLS CUI [1]
C1704258
Augen
Descripción

Augen

Alias
UMLS CUI-1
C0015392
Pupil Right Size [mm]
Descripción

Right Pupil Size

Tipo de datos

integer

Unidades de medida
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205090
mm
Pupil Right Reaction
Descripción

Right Pupil Reaction

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
Pupil Left Size [mm]
Descripción

Left Pupil Size

Tipo de datos

integer

Unidades de medida
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205091
mm
Pupil Left Reaction
Descripción

Left Pupil Reaction

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
Eye Complains
Descripción

Eye symptom

Tipo de datos

text

Alias
UMLS CUI [1]
C0848690
Right Sclera
Descripción

Right Sclera

Tipo de datos

text

Alias
UMLS CUI [1]
C0929516
Left Sclera
Descripción

Left Sclera

Tipo de datos

text

Alias
UMLS CUI [1]
C0934600
Drainage
Descripción

Drainage

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0012621
Drainage Color
Descripción

Drainage Color

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0012621
UMLS CUI [1,2]
C0009393
Ohren
Descripción

Ohren

Alias
UMLS CUI-1
C0013443
EARS(EXTERNAL CANAL)
Descripción

EXTERNAL CANAL

Tipo de datos

text

Alias
UMLS CUI [1]
C1517034
C/O Pain
Descripción

C/O Pain

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0436561
Trommelfell
Descripción

Tympanic Membranes

Tipo de datos

text

Alias
SNOMED CT 2011_0131
42859004
LOINC Version 232
MTHU014731
UMLS CUI [1]
C0041445
Tubes
Descripción

Tubes

Tipo de datos

text

Alias
UMLS CUI [1]
C0015183
Hard of Hearing
Descripción

Hard of Hearing

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1384666
Hearing Loss
Descripción

Hearing Loss

Tipo de datos

boolean

Alias
UMLS CUI [1]
C3887873
Deafness
Descripción

Deafness

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0011053
Hearing Aids
Descripción

Hearing Aids

Tipo de datos

text

Alias
UMLS CUI [1]
C0018768
Patent
Descripción

Patent

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0175566
Schwindel
Descripción

Dizziness

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0012833
SNOMED CT 2011_0131
404640003
MedDRA 14.1
10013573
CTCAE 1105E
E12631
Tinnitus
Descripción

Tinnitus

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0040264
SNOMED CT 2011_0131
60862001
MedDRA 14.1
10043882
ICD-10-CM Version 2010
H93.1
ICD-9-CM Version 2011
388.3
CTCAE 1105E
E10287
Drainage
Descripción

Drainage

Tipo de datos

boolean

Alias
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
UMLS CUI [1]
C0012621
Color of Ear Drainage
Descripción

Color of Ear Drainage

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0012621
UMLS CUI [1,2]
C0009393
Nase
Descripción

Nase

Alias
UMLS CUI-1
C0028429
Nares patent
Descripción

Nares patent

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1456808
UMLS CUI [1,2]
C0175566
Nares Drainage
Descripción

Nares Drainage

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0746759
Nasenseptum
Descripción

Septum

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0027432
SNOMED CT 2011_0131
68426009
LOINC Version 232
MTHU015054
Pharynx
Descripción

Pharynx

Alias
UMLS CUI-1
C0031354
Sore throat, Pain in throat, Pharyngeal pain
Descripción

Throat Pain

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0242429
SNOMED CT 2011_0131
267102003
MedDRA 14.1
10041367
ICD-10-CM Version 2010
R07.0
ICD-9-CM Version 2011
784.1
CTCAE 1105E
E13575
Mouth Sores
Descripción

Mouth Sores

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0149745
Appearance of Throat
Descripción

Appearance of Throat

Tipo de datos

text

Alias
UMLS CUI [1]
C0426505
Mucous Membranes
Descripción

Mucous Membranes

Tipo de datos

text

Alias
UMLS CUI [1]
C0026724
Respiratory
Descripción

Respiratory

Alias
UMLS CUI-1
C0035237
Normal Baseline Respiratory: Unlabored respirations, BBS clear, chest rise symmetrical, pink mucous membranes.
Descripción

Respiratory NORMAL

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0231795
NARRATIVE: Abnormal Findings
Descripción

Abnormal Findings

Tipo de datos

text

Alias
UMLS CUI [1]
C1704258
Atemgeräusch
Descripción

BREATH SOUNDS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0035234
SNOMED CT 2011_0131
52653008
MedDRA 14.1
10064779
RESPIRATORY EFFORT
Descripción

RESPIRATORY EFFORT

Tipo de datos

text

Alias
UMLS CUI [1]
C0425466
CHEST EXPANSION
Descripción

CHEST EXPANSION

Tipo de datos

text

Alias
UMLS CUI [1]
C0231902
INCENTIVE SPIROMETRY DONE
Descripción

INCENTIVE SPIROMETRY

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0454512
OXYGEN DELIVERY METHOD
Descripción

oxygen delivery system

Tipo de datos

text

Alias
UMLS CUI [1]
C0809836
Pulse Oximeter present with alarms set
Descripción

Pulse Oximeter

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0182109
Cardio-Respriratory Monitor present with alarms set
Descripción

Cardio-Respiratory Monitoring

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0150496
UMLS CUI [1,2]
C0199438
Husten
Descripción

COUGH TYPE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0010200
SNOMED CT 2011_0131
49727002
MedDRA 14.1
10011224
ICD-10-CM Version 2010
R05
ICD-9-CM Version 2011
786.2
CTCAE 1105E
E13364
Sputum
Descripción

Sputum

Tipo de datos

text

Alias
SNOMED CT 2011_0131
45710003
MedDRA 14.1
10041802
LOINC Version 232
MTHU001309
UMLS CUI [1]
C0038056
CHEST TUBE PRESENT
Descripción

CHEST TUBE

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0008034
CHEST TUBE LOCATION
Descripción

Chest tube site

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0489468
Chest Tube Suction Setting
Descripción

Chest Tube Suction Setting

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0008034
UMLS CUI [1,2]
C1306323
Air Leak
Descripción

Air Leak

Tipo de datos

text

Alias
UMLS CUI [1]
C2242512
Gastrointestinal
Descripción

Gastrointestinal

Normal Baseline GI: Abdomen soft, nondistended, bowel sounds normoactive in all quadrants.
Descripción

NORMAL BASELINE GI

Tipo de datos

boolean

Last Bowel Movement
Descripción

Last BM

Tipo de datos

date

NARRATIVE: Abnormal Findings
Descripción

NARRATIVE: Abnormal Findings

Tipo de datos

string

Abdomen
Descripción

ABDOMINAL DESCRIPTION

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Darmgeräusche
Descripción

BOWEL SOUNDS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0232693
SNOMED CT 2011_0131
87042004
MedDRA 14.1
10006023
FLATUS
Descripción

FLATUS

Tipo de datos

boolean

Inkontinenz
Descripción

incontinence

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0021167
SNOMED CT 2011_0131
48340000
MedDRA 14.1
10021639
GASTRIC SYMPTOMS
Descripción

GASTRIC SYMPTOMS

Tipo de datos

string

Nasogastric Tube Type
Descripción

NG TUBE TYPE

Tipo de datos

string

NG placement checked
Descripción

NG placement checked

Tipo de datos

boolean

Suction Setting
Descripción

Suction Setting

Tipo de datos

string

Gastric Content Color
Descripción

Gastric Content Color

Tipo de datos

string

NGT irrigated (with # ML's of #)
Descripción

NGT irrigated

Tipo de datos

string

Ernährung über Sonde
Descripción

FEEDING TUBE PRESENT

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Feeding Tube Type
Descripción

Feeding Tube Type

Tipo de datos

string

Formula (# strength @ # ml's/hour via kangaroo pump)
Descripción

Formula

Tipo de datos

string

OSTOMY TYPE
Descripción

OSTOMY TYPE

Tipo de datos

string

RECTAL BAG PRESENT
Descripción

RECTAL BAG PRESENT

Tipo de datos

boolean

Urogenitales System
Descripción

Urogenitales System

Normal Baseline Genitourinary: Voids without pain or hesitation, no suprapubic distention.
Descripción

NORMAL BASELINE Genitourinary

Tipo de datos

boolean

NARRATIVE: Abnormal Findings
Descripción

NARRATIVE: Abnormal Findings

Tipo de datos

string

Geschlecht
Descripción

Sex

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0079399
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
INCONTINENT
Descripción

INCONTINENT

Tipo de datos

boolean

VOIDS SUFFICIENT QUANITY
Descripción

VOIDS SUFFICIENT QUANITY

Tipo de datos

boolean

IS PATIENT RECEIVING DIALYSIS
Descripción

IS PATIENT RECEIVING DIALYSIS

Tipo de datos

boolean

ODOR PRESENT
Descripción

ODOR PRESENT

Tipo de datos

boolean

Katheter
Descripción

CATHETER PRESENT

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0085590
SNOMED CT 2011_0131
19923001
Katheter-Größe
Descripción

CATHETER SIZE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0449963
SNOMED CT 2011_0131
260967009
Date of insertion
Descripción

Date of insertion

Tipo de datos

date

Urine color
Descripción

Urine color

Tipo de datos

string

URINARY SYMPTOMS
Descripción

URINARY SYMPTOMS

Tipo de datos

string

SEXUALLY ACTIVE
Descripción

SEXUALLY ACTIVE

Tipo de datos

boolean

CURRENTLY ON MENSES
Descripción

CURRENTLY ON MENSES

Tipo de datos

boolean

Ausfluss
Descripción

DISCHARGE PRESENT

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0012621
SNOMED CT 2011_0131
75823008
Discharge color
Descripción

Discharge color

Tipo de datos

string

Discharge odor
Descripción

Discharge odor

Tipo de datos

string

Discharge consistency
Descripción

Discharge consistency

Tipo de datos

string

ABNORMAL GENITALIA DESCRIPTION
Descripción

ABNORMAL GENITALIA DESCRIPTION

Tipo de datos

string

Muskuloskeletales System
Descripción

Muskuloskeletales System

Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, bones intact, gait steady or age appropriate.
Descripción

NORMAL BASELINE Musculoskeletal

Tipo de datos

boolean

NARRATIVE: Abnormal Findings
Descripción

NARRATIVE: Abnormal Findings

Tipo de datos

string

GENERALIZED WEAKNESS
Descripción

GENERALIZED WEAKNESS

Tipo de datos

boolean

LIMITED ROM
Descripción

LIMITED ROM

Tipo de datos

boolean

LIMITED MOBILITY
Descripción

LIMITED MOBILITY

Tipo de datos

boolean

PARALYSIS TYPE
Descripción

PARALYSIS TYPE

Tipo de datos

string

Hemiplegia Side
Descripción

Hemiplegia Side

Tipo de datos

string

FRACTURE(S) LOCATION
Descripción

FRACTURE(S) LOCATION

Tipo de datos

string

FINGER DIGITS
Descripción

FINGER DIGITS

Tipo de datos

string

TOE DIGITS
Descripción

TOE DIGITS

Tipo de datos

string

LEFT UPPER EXTREMITIES
Descripción

LEFT UPPER EXTREMITIES

Tipo de datos

string

RIGHT UPPER EXTREMITIES
Descripción

RIGHT UPPER EXTREMITIES

Tipo de datos

string

GRIPS EQUAL
Descripción

GRIPS EQUAL

Tipo de datos

boolean

LEFT LOWER EXTREMITIES
Descripción

LEFT LOWER EXTREMITIES

Tipo de datos

string

RIGHT LOWER EXTREMITIES
Descripción

RIGHT LOWER EXTREMITIES

Tipo de datos

string

UNSTEADY GAIT
Descripción

UNSTEADY GAIT

Tipo de datos

boolean

Haut
Descripción

Haut

Normal Baseline Skin: Warm, pink, dry, elastic, intact, moist mucous membranes.
Descripción

NORMAL BASELINE Skin

Tipo de datos

boolean

NARRATIVE: Abnormal Findings
Descripción

NARRATIVE: Abnormal Findings

Tipo de datos

string

Temperatur
Descripción

TEMPERATURE

Tipo de datos

float

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
SKIN COLOR
Descripción

SKIN COLOR

Tipo de datos

string

MOIST
Descripción

MOIST

Tipo de datos

boolean

SKIN TURGOR
Descripción

SKIN TURGOR

Tipo de datos

string

Inzision
Descripción

Inzision

Inzision
Descripción

Incision #:

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0184898
SNOMED CT 2011_0131
34896006
MID WOUND#
Descripción

MID WOUND#

Tipo de datos

string

Site
Descripción

Site

Tipo de datos

string

Closure Type
Descripción

Closure Type

Tipo de datos

string

Incision Appearance
Descripción

Incision Appearance

Tipo de datos

string

Dressing Changed
Descripción

Dressing Changed

Tipo de datos

boolean

Date Dressing Changed
Descripción

Date Dressing Changed

Tipo de datos

date

Dressing Type
Descripción

Dressing Type

Tipo de datos

string

Dressing Appearance
Descripción

Dressing Appearance

Tipo de datos

string

Drainage
Descripción

Drains

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0180499
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
Wunde
Descripción

Wunde

Wunde
Descripción

WOUND #

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
MID WOUND#
Descripción

MID WOUND#

Tipo de datos

string

Wound Location
Descripción

Wound Location

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
UMLS CUI 2011AA-2
C0450429
SNOMED CT 2011_0131-2
246267002
Length (cm, mm)
Descripción

Length (cm, mm)

Tipo de datos

string

Width (cm, mm)
Descripción

Width (cm, mm)

Tipo de datos

string

Depth (cm, mm)
Descripción

Depth (cm, mm)

Tipo de datos

string

Undermining
Descripción

Undermining

Tipo de datos

boolean

Tunneling
Descripción

Tunneling

Tipo de datos

boolean

Surrounding Skin
Descripción

Surrounding Skin

Tipo de datos

string

Wound Base
Descripción

Wound Base

Tipo de datos

string

Exsudat
Descripción

Exudate

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0015388
SNOMED CT 2011_0131
247450001
LOINC Version 232
MTHU025016
Exudate Color
Descripción

Exudate Color

Tipo de datos

string

Sensation
Descripción

Sensation

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
Odor: Before Cleaning
Descripción

Odor: Before Cleaning

Tipo de datos

boolean

Odor: After Cleaning
Descripción

Odor: After Cleaning

Tipo de datos

boolean

Cleansed with/irrigated with
Descripción

Cleansed with/irrigated with

Tipo de datos

string

Wound Medication Applied
Descripción

Wound Medication Applied

Tipo de datos

string

Wound Filled with
Descripción

Wound Filled with

Tipo de datos

string

Wound covered with
Descripción

Wound covered with

Tipo de datos

string

Wound secured with
Descripción

Wound secured with

Tipo de datos

string

Wound Pressure Relief
Descripción

Wound Pressure Relief

Tipo de datos

string

Comments
Descripción

Comments

Tipo de datos

string

Photograph Date
Descripción

Photograph Date

Tipo de datos

date

RASH LOCATION
Descripción

RASH LOCATION

Tipo de datos

string

RASH DESCRIPTION
Descripción

RASH DESCRIPTION

Tipo de datos

string

TATTOO'S/PIERCINGS
Descripción

TATTOO'S/PIERCINGS

Tipo de datos

string

SKIN TEARS, LOCATION/ Description
Descripción

SKIN TEARS, LOCATION/ Description

Tipo de datos

string

SPECIALTY BEDS
Descripción

SPECIALTY BEDS

Tipo de datos

string

Nutrition
Descripción

Nutrition

Diät
Descripción

Current Diet

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
NPO
Descripción

NPO

Tipo de datos

boolean

Ernährung über Sonde
Descripción

FEEDING TUBE PRESENT

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Feeding Tube Type
Descripción

Feeding Tube Type

Tipo de datos

string

Formula: # strength @ # cc's/hour via kangaroo pump
Descripción

Formula

Tipo de datos

string

RESIDUALS CHECKED: AMOUNT # CC
Descripción

RESIDUALS CHECKED

Tipo de datos

string

BREAKFAST
Descripción

BREAKFAST

Tipo de datos

string

Breakfast: Amount taken
Descripción

Breakfast: Amount taken

Tipo de datos

string

Breakfast: Patient fed by
Descripción

Breakfast: Patient fed by

Tipo de datos

string

LUNCH
Descripción

LUNCH

Tipo de datos

string

Lunch: Amount taken
Descripción

Lunch: Amount taken

Tipo de datos

string

Lunch: Patient fed by
Descripción

Lunch: Patient fed by

Tipo de datos

string

SUPPER
Descripción

SUPPER

Tipo de datos

string

Supper: Amount taken
Descripción

Supper: Amount taken

Tipo de datos

string

Supper: Patient fed by
Descripción

Supper: Patient fed by

Tipo de datos

string

Supper: Amount taken
Descripción

Supper: Amount taken

Tipo de datos

string

intravenöse Therapie
Descripción

intravenöse Therapie

NARRATIVE: IV Therapy
Descripción

NARRATIVE: IV Therapy

Tipo de datos

string

IV HEPLOCKED
Descripción

IV HEPLOCKED

Tipo de datos

boolean

IV Site APPEARANCE
Descripción

IV Site APPEARANCE

Tipo de datos

string

IV DISCONTINUED
Descripción

IV DISCONTINUED

Tipo de datos

boolean

CATHETER INTACT
Descripción

CATHETER INTACT

Tipo de datos

boolean

IV Catheter Size
Descripción

IV Catheter Size

Tipo de datos

string

IV Site Location
Descripción

IV Site Location

Tipo de datos

string

Zentralvenöser Katheter (ZVK)
Descripción

CENTRAL LINE PORT

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1145640
SNOMED CT 2011_0131
52124006
Infusion
Descripción

IV FLUIDS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
Left to count:
Descripción

Left to count:

Tipo de datos

string

IV Fluid Rate: @ ml/hr
Descripción

IV Fluid Rate: @ ml/hr

Tipo de datos

integer

TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Descripción

TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr

Tipo de datos

string

PCA PUMP: at @ cc's/hr
Descripción

PCA PUMP: at @ cc's/hr

Tipo de datos

string

IV Site APPEARANCE
Descripción

IV Site APPEARANCE

Tipo de datos

string

INSERTION DATE
Descripción

INSERTION DATE

Tipo de datos

date

DRESSING CHANGE DUE
Descripción

DRESSING CHANGE DUE

Tipo de datos

date

SITE CHANGE DUE
Descripción

SITE CHANGE DUE

Tipo de datos

date

PLACED ON IMED
Descripción

PLACED ON IMED

Tipo de datos

boolean

Patientensicherheit
Descripción

Patientensicherheit

SIDE RAILS UP
Descripción

SIDE RAILS UP

Tipo de datos

boolean

IN LOW POSTION
Descripción

IN LOW POSTION

Tipo de datos

boolean

BED/CRIB
Descripción

BED/CRIB

Tipo de datos

string

CALL BELL WITHIN REACH
Descripción

CALL BELL WITHIN REACH

Tipo de datos

boolean

ALLERGY BAND ON
Descripción

ALLERGY BAND ON

Tipo de datos

boolean

NAME BAND ON
Descripción

NAME BAND ON

Tipo de datos

boolean

BLOOD BAND ON
Descripción

BLOOD BAND ON

Tipo de datos

boolean

FALL BAND ON
Descripción

FALL BAND ON

Tipo de datos

boolean

BED SAFETY
Descripción

BED SAFETY

Tipo de datos

string

Pediatric Fall Risk Assessment
Descripción

Pediatric Fall Risk Assessment

Unable to assess fall risk status at this time due to patient is:
Descripción

Unable to assess fall risk status at this time due to patient is:

Tipo de datos

string

Geschlecht
Descripción

gender

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0079399
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
Bewusstseinslage
Descripción

LEVEL OF CONSCIOUS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0234421
SNOMED CT 2011_0131
106167005
Seizures/Previous history of falls
Descripción

Seizures/Previous history of falls

Tipo de datos

string

MEDICATION/EQUIPMENT
Descripción

MEDICATION/EQUIPMENT

Tipo de datos

string

Verweildauer
Descripción

LENGTH OF STAY

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0023303
ELIMINATION
Descripción

ELIMINATION

Tipo de datos

string

GET UP AND GO TEST: "RISING FROM A CHAIR"
Descripción

GET UP AND GO TEST: "RISING FROM A CHAIR"

Tipo de datos

string

FINAL RISK SCORE (Pediatric Fall Risk Assessment)
Descripción

FINAL RISK SCORE

Tipo de datos

integer

INTERVENTIONS
Descripción

INTERVENTIONS

Assist with Ambulation
Descripción

Assist with Ambulation

Tipo de datos

boolean

Reorient Q2H or Less
Descripción

Reorient Q2H or Less

Tipo de datos

boolean

Gait Belt
Descripción

Gait Belt

Tipo de datos

boolean

ID Patient at Risk
Descripción

ID Patient at Risk

Tipo de datos

boolean

Restraints (see policy)
Descripción

Restraints (see policy)

Tipo de datos

boolean

Multi-personnel Transfer
Descripción

Multi-personnel Transfer

Tipo de datos

boolean

Close Observation
Descripción

Close Observation

Tipo de datos

boolean

Non-slip Footwear
Descripción

Non-slip Footwear

Tipo de datos

boolean

Bed in lowest position
Descripción

Bed in lowest position

Tipo de datos

boolean

Lock wheels of vehicles of conveyance during transfer
Descripción

Lock wheels of vehicles of conveyance during transfer

Tipo de datos

boolean

Upper siderails raised
Descripción

Upper siderails raised

Tipo de datos

boolean

Call light in reach
Descripción

Call light in reach

Tipo de datos

boolean

Offer toileting at least every 2 hours
Descripción

Offer toileting at least every 2 hours

Tipo de datos

boolean

Offer fluid/nutrition every 2 hours
Descripción

Offer fluid/nutrition every 2 hours

Tipo de datos

boolean

Place frequently used objects within reach
Descripción

Place frequently used objects within reach

Tipo de datos

boolean

Provide adequate lighting
Descripción

Provide adequate lighting

Tipo de datos

boolean

Provide sensory impairment/orientation devices (clocks,etc)
Descripción

Provide sensory impairment/orientation devices (clocks,etc)

Tipo de datos

boolean

Provide adequate rest periods
Descripción

Provide adequate rest periods

Tipo de datos

boolean

Use age appropriate distractions for confusion/disorientation
Descripción

Use age appropriate distractions for confusion/disorientation

Tipo de datos

boolean

Remove harmful hazards
Descripción

Remove harmful hazards

Tipo de datos

boolean

Provide appropriate and least restrictive patient supervision/surveillance
Descripción

Provide appropriate and least restrictive patient supervision/surveillance

Tipo de datos

boolean

Communicate information about fall risk to caregivers
Descripción

Communicate information about fall risk to caregivers

Tipo de datos

boolean

Encourage family/support system to participate in care
Descripción

Encourage family/support system to participate in care

Tipo de datos

boolean

Teach/educate family/support system Fall Prevention information
Descripción

Teach/educate family/support system Fall Prevention information

Tipo de datos

boolean

Implement Fall Prevention Protocol for Hendrich II Score>5
Descripción

Implement Fall Prevention Protocol for Hendrich II Score>5

Tipo de datos

boolean

IMPAIRED MOBILITY RISK
Descripción

IMPAIRED MOBILITY RISK

Implement Universal Fall Prevention Intervention
Descripción

Implement Universal Fall Prevention Intervention

Tipo de datos

boolean

Monitor transfers to/from bed/chair(etc.)
Descripción

Monitor transfers to/from bed/chair(etc.)

Tipo de datos

boolean

Use appropriate assistance for transfers to/from bed/chair
Descripción

Use appropriate assistance for transfers to/from bed/chair

Tipo de datos

boolean

Use chairs with armrests and of proper height for transfers
Descripción

Use chairs with armrests and of proper height for transfers

Tipo de datos

boolean

Implement progressive ambulation(unless contraindicated by condition/orders)
Descripción

Implement progressive ambulation(unless contraindicated by condition/orders)

Tipo de datos

boolean

Encourage/Provide self-care assistance
Descripción

Encourage/Provide self-care assistance

Tipo de datos

boolean

Remain in attendance during toileting/ADL's
Descripción

Remain in attendance during toileting/ADL's

Tipo de datos

boolean

Provide assistive devices for ambulation (canes/walkers/etc.)
Descripción

Provide assistive devices for ambulation (canes/walkers/etc.)

Tipo de datos

boolean

Gait Belt during transport/ambulation
Descripción

Gait Belt during transport/ambulation

Tipo de datos

boolean

Teach patient/family to call for help and WAIT for help before
Descripción

Teach patient/family to call for help and WAIT for help before

Tipo de datos

boolean

attempting any transfer/ambulation
Descripción

attempting any transfer/ambulation

Tipo de datos

boolean

ALTERED ELIMINATION
Descripción

ALTERED ELIMINATION

Implement Universal Fall Prevention Interventions
Descripción

Implement Universal Fall Prevention Interventions

Tipo de datos

boolean

Remain in attendance during toileting/ADL's
Descripción

Remain in attendance during toileting/ADL's

Tipo de datos

boolean

Assist with post-elimination hygiene
Descripción

Assist with post-elimination hygiene

Tipo de datos

boolean

Remove non-essential clothing
Descripción

Remove non-essential clothing

Tipo de datos

boolean

Instruct patient on importance of toileting when offered by staff
Descripción

Instruct patient on importance of toileting when offered by staff

Tipo de datos

boolean

Monitor for 'patient's normal' bladder/bowel habits
Descripción

Monitor for 'patient's normal' bladder/bowel habits

Tipo de datos

boolean

Monitor for causes of incontinence (diuretics,cathartics,etc.)
Descripción

Monitor for causes of incontinence (diuretics,cathartics,etc.)

Tipo de datos

boolean

Monitor skin integrity
Descripción

Monitor skin integrity

Tipo de datos

boolean

HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Descripción

HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)

Implement Universal Fall Prevention Interventions
Descripción

Implement Universal Fall Prevention Interventions

Tipo de datos

boolean

Monitor drug dosages
Descripción

Monitor drug dosages

Tipo de datos

boolean

Evaluate sensory functions
Descripción

Evaluate sensory functions

Tipo de datos

boolean

Monitor/Assess for drug overdose
Descripción

Monitor/Assess for drug overdose

Tipo de datos

boolean

Monitor response to exercise
Descripción

Monitor response to exercise

Tipo de datos

boolean

Educate patient/support system about drug classification, side effects,
Descripción

Educate patient/support system about drug classification, side effects,

Tipo de datos

boolean

precautions, toxic symptoms of overdose.
Descripción

precautions, toxic symptoms of overdose.

Tipo de datos

boolean

Hendrich II Fall Risk Assessment
Descripción

Hendrich II Fall Risk Assessment

Unable to assess fall risk status at this time due to patient is:
Descripción

Unable to assess fall risk status at this time due to patient is:

Tipo de datos

string

HENDRICH CALCULATION
Descripción

HENDRICH CALCULATION

Tipo de datos

string

ONN Unit specific
Descripción

ONN Unit specific

AFFECTED SITE
Descripción

AFFECTED SITE

Tipo de datos

string

CIRCULATORY STATUS
Descripción

CIRCULATORY STATUS

Tipo de datos

string

SKIN COLOR
Descripción

SKIN COLOR

Tipo de datos

string

SENSATION
Descripción

SENSATION

Tipo de datos

string

MOVEMENT
Descripción

MOVEMENT

Tipo de datos

string

Temperatur
Descripción

TEMPERATURE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
Hautzustand
Descripción

SKIN CONDITION

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1719933
SNOMED CT 2011_0131
422000003
LOINC Version 232
MTHU034830
PULSE(s) SITE(s)
Descripción

PULSE(s) SITE(s)

Tipo de datos

string

RESPONSE
Descripción

RESPONSE

Tipo de datos

string

POSITION OF LIMB
Descripción

POSITION OF LIMB

Tipo de datos

string

ORTHOPEDIC DEVICE IN USE
Descripción

ORTHOPEDIC DEVICE IN USE

Tipo de datos

string

CONTINUOUS PASSIVE MOTION
Descripción

CONTINUOUS PASSIVE MOTION

Tipo de datos

string

POUNDS
Descripción

POUNDS

Tipo de datos

string

CERVICAL COLLARS
Descripción

CERVICAL COLLARS

Tipo de datos

string

AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
Descripción

AFO BRACE: Foot/Feet

Tipo de datos

string

SWELLING
Descripción

SWELLING

Tipo de datos

string

PIN SITES
Descripción

PIN SITES

Tipo de datos

string

CLEANED WITH
Descripción

CLEANED WITH

Tipo de datos

string

NARRATIVE
Descripción

NARRATIVE

Tipo de datos

string

Post Surgical
Descripción

Post Surgical

Patient activity
Descripción

General Activity

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0451369
SNOMED CT 2011_0131
273688003
Vaginal Packing
Descripción

Vaginal Packing

Tipo de datos

string

Equipment/Devices
Descripción

Equipment/Devices

Tipo de datos

string

EQUIPMENT/DEVICES
Descripción

EQUIPMENT/DEVICES

Tipo de datos

string

ADOLESCENT INTERACTION
Descripción

ADOLESCENT INTERACTION

Prepared for treatment/procedure as soon as possible.
Descripción

Prepared for treatment/procedure as soon as possible.

Tipo de datos

string

Provided detailed information about events/procedures/treatments.
Descripción

Provided detailed information about events/procedures/treatments.

Tipo de datos

string

Allowed contact with peer group.
Descripción

Allowed contact with peer group.

Tipo de datos

string

NARRATIVE
Descripción

NARRATIVE

Tipo de datos

string

GERIATRIC INTERVENTION (65+)
Descripción

GERIATRIC INTERVENTION (65+)

Involved in decision process regarding pain control/medication/care decisions
Descripción

Involved in decision process regarding pain control/medication/care decisions

Tipo de datos

string

Encouraged family/S.O.to visit
Descripción

Encouraged family/S.O.to visit

Tipo de datos

string

Independence promoted.
Descripción

Independence promoted.

Tipo de datos

string

NARRATIVE
Descripción

NARRATIVE

Tipo de datos

string

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Child Nursing Assessment
C0028680 (UMLS CUI-1)
C0008059 (UMLS CUI-2)
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])
POST OP DAY
Item
POST OP DAY
integer
C0032790 (UMLS CUI [1])
Item Group
Neuro / Psychosocial
C0027853 (UMLS CUI-1)
Neurological examination normal
Item
Normal Baseline: Alert, appropriate verbalization, response appropriate for age, pupils equal and reactive, sensation intact.
boolean
C1112287 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
GLASGOW COMA SCALE ADULT
C1271007 (UMLS CUI-1)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
Code List
EYES OPEN
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)
Item
BEST VERBAL RESPONSE
integer
C3648957 (UMLS CUI [1])
Code List
BEST VERBAL RESPONSE
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)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
Code List
BEST MOTOR RESPONSE
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])
Item Group
Pupillen
C0034121 (UMLS CUI-1)
Right Pupil Size
Item
Right Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Left Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Item Group
GLASGOW COMA SCALE CHILD
C0017594 (UMLS CUI-1)
C0008059 (UMLS CUI-2)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
Code List
EYES OPEN
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)
Item
BEST VERBAL RESPONSE
integer
Code List
BEST VERBAL RESPONSE
CL Item
Coos and babbles (5)
C0517058 (UMLS CUI-1)
CL Item
Irritable, cries (4)
C0010399 (UMLS CUI-1)
CL Item
Cries in response to pain (3)
C1698479 (UMLS CUI-1)
CL Item
Moans in response to pain (2)
C2071460 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
Code List
BEST MOTOR RESPONSE
CL Item
Moves spontaneously and purposely (6)
C2012055 (UMLS CUI-1)
CL Item
Withdraws in response to touch (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws in response to pain (4)
C2012052 (UMLS CUI-1)
CL Item
Decorticate posturing (abnormal flexion) in response to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Decerebrate posturing (abnormal extension) in response to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE CHILD
Item
GLASCOW COMA SCALE SCORE CHILD
integer
Item Group
ORIENTATION
C0029266 (UMLS CUI-1)
ORIENTATION
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
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)
SPEECH
Item
Sprache
string
C0037817 (UMLS CUI 2011AA)
87335007 (SNOMED CT 2011_0131)
MTHU021528 (LOINC Version 232)
NUMBNESS OR TINGLING
Item
NUMBNESS OR TINGLING PRESENT
text
C3842982 (UMLS CUI [1])
Item Group
Kardiovaskuläres System
C0007226 (UMLS CUI-1)
Cardiovascular System Normal
Item
Normal Baseline: Regular rate and rhythm, no edema, capillary refill less than 2 seconds, pink nailbeds, warm extemities, peripheral pulses strong and regular.
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)
Radial pulse (L/R)
Item
Radial pulse (L/R)
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pedal pulse
Item
Pedal pulse (L/R)
text
C0232157 (UMLS CUI [1])
Pos-Tibial Pulse
Item
Tibialis posterior-Puls (L/R)
text
421568004 (SNOMED CT 2011_0131)
C1720310 (UMLS CUI [1])
Popliteal Pulse (L/R)
Item
Popliteal-Puls (L/R)
string
C0232151 (UMLS CUI 2011AA)
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)
Carotid Pulse (L/R)
Item
Karotis-Puls (L/R)
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
AV SHUNT
Item
AV SHUNT/GRAFT
text
C1456474 (UMLS CUI [1])
SHUNT LOCATION
Item
SHUNT/GRAFT LOCATION
text
C1442858 (UMLS CUI [1,1])
C0450429 (UMLS CUI [1,2])
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)
Heart RHYTHM
Item
Heart RHYTHM
text
C0232187 (UMLS CUI [1])
PACEMAKER PRESENT
Item
(künstlicher) Herzschrittmacher
boolean
C0030163 (UMLS CUI 2011AA)
14106009 (SNOMED CT 2011_0131)
MTHU024521 (LOINC Version 232)
Item Group
Eyes Ear Nose & Throat
C3494720 (UMLS CUI-1)
EYES NORMAL
Item
Normal Baseline EYES: Without drainage, sclera white.
boolean
C4230579 (UMLS CUI [1])
Normal Ears
Item
Normal Baseline EARS: No complaint of pain.
boolean
C4230157 (UMLS CUI [1])
Normal Nose
Item
Normal Baseline NOSE: No drainage or congestion.
boolean
C0577884 (UMLS CUI [1])
Normal Throat
Item
Normal Baseline THROAT: No complaint of pain.
boolean
C0577002 (UMLS CUI [1])
Abnormal Findings
Item
NARRATIVE: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
Augen
C0015392 (UMLS CUI-1)
Right Pupil Size
Item
Pupil Right Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Pupil Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Pupil Left Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Pupil Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Eye symptom
Item
Eye Complains
text
C0848690 (UMLS CUI [1])
Right Sclera
Item
Right Sclera
text
C0929516 (UMLS CUI [1])
Left Sclera
Item
Left Sclera
text
C0934600 (UMLS CUI [1])
Drainage
Item
Drainage
boolean
C0012621 (UMLS CUI [1])
Drainage Color
Item
Drainage Color
text
C0012621 (UMLS CUI [1,1])
C0009393 (UMLS CUI [1,2])
Item Group
Ohren
C0013443 (UMLS CUI-1)
EXTERNAL CANAL
Item
EARS(EXTERNAL CANAL)
text
C1517034 (UMLS CUI [1])
C/O Pain
Item
C/O Pain
boolean
C0436561 (UMLS CUI [1])
Tympanic Membranes
Item
Trommelfell
text
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
C0041445 (UMLS CUI [1])
Tubes
Item
Tubes
text
C0015183 (UMLS CUI [1])
Hard of Hearing
Item
Hard of Hearing
boolean
C1384666 (UMLS CUI [1])
Hearing Loss
Item
Hearing Loss
boolean
C3887873 (UMLS CUI [1])
Deafness
Item
Deafness
boolean
C0011053 (UMLS CUI [1])
Item
Hearing Aids
text
C0018768 (UMLS CUI [1])
Code List
Hearing Aids
CL Item
RT (1)
C0444532 (UMLS CUI-1)
CL Item
LT (2)
C0443246 (UMLS CUI-1)
CL Item
bilateral (3)
C0238767 (UMLS CUI-1)
Patent
Item
Patent
boolean
C0175566 (UMLS CUI [1])
Dizziness
Item
Schwindel
boolean
C0012833 (UMLS CUI 2011AA)
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)
Drainage
Item
Drainage
boolean
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
C0012621 (UMLS CUI [1])
Color of Ear Drainage
Item
Color of Ear Drainage
text
C0012621 (UMLS CUI [1,1])
C0009393 (UMLS CUI [1,2])
Item Group
Nase
C0028429 (UMLS CUI-1)
Nares patent
Item
Nares patent
boolean
C1456808 (UMLS CUI [1,1])
C0175566 (UMLS CUI [1,2])
Nares Drainage
Item
Nares Drainage
boolean
C0746759 (UMLS CUI [1])
Septum
Item
Nasenseptum
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Item Group
Pharynx
C0031354 (UMLS CUI-1)
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)
Mouth Sores
Item
Mouth Sores
boolean
C0149745 (UMLS CUI [1])
Appearance of Throat
Item
Appearance of Throat
text
C0426505 (UMLS CUI [1])
Mucous Membranes
Item
Mucous Membranes
text
C0026724 (UMLS CUI [1])
Item Group
Respiratory
C0035237 (UMLS CUI-1)
Respiratory NORMAL
Item
Normal Baseline Respiratory: Unlabored respirations, BBS clear, chest rise symmetrical, pink mucous membranes.
boolean
C0231795 (UMLS CUI [1])
Abnormal Findings
Item
NARRATIVE: Abnormal Findings
text
C1704258 (UMLS CUI [1])
BREATH SOUNDS
Item
Atemgeräusch
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
RESPIRATORY EFFORT
Item
RESPIRATORY EFFORT
text
C0425466 (UMLS CUI [1])
Item
CHEST EXPANSION
text
C0231902 (UMLS CUI [1])
Code List
CHEST EXPANSION
CL Item
symmetrical (1)
C0332516 (UMLS CUI-1)
CL Item
non-symmetrical (2)
C0332514 (UMLS CUI-1)
INCENTIVE SPIROMETRY
Item
INCENTIVE SPIROMETRY DONE
boolean
C0454512 (UMLS CUI [1])
oxygen delivery system
Item
OXYGEN DELIVERY METHOD
text
C0809836 (UMLS CUI [1])
Pulse Oximeter
Item
Pulse Oximeter present with alarms set
boolean
C0182109 (UMLS CUI [1])
Cardio-Respiratory Monitoring
Item
Cardio-Respriratory Monitor present with alarms set
boolean
C0150496 (UMLS CUI [1,1])
C0199438 (UMLS CUI [1,2])
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)
Sputum
Item
Sputum
text
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
C0038056 (UMLS CUI [1])
CHEST TUBE
Item
CHEST TUBE PRESENT
boolean
C0008034 (UMLS CUI [1])
Chest tube site
Item
CHEST TUBE LOCATION
boolean
C0489468 (UMLS CUI [1])
Chest Tube Suction Setting
Item
Chest Tube Suction Setting
text
C0008034 (UMLS CUI [1,1])
C1306323 (UMLS CUI [1,2])
Item
Air Leak
text
C2242512 (UMLS CUI [1])
Code List
Air Leak
CL Item
none (1)
C0549184 (UMLS CUI-1)
CL Item
small (2)
C0700321 (UMLS CUI-1)
CL Item
moderate (3)
C0205081 (UMLS CUI-1)
CL Item
large (4)
C0549177 (UMLS CUI-1)
Item Group
Gastrointestinal
NORMAL BASELINE GI
Item
Normal Baseline GI: Abdomen soft, nondistended, bowel sounds normoactive in all quadrants.
boolean
Last BM
Item
Last Bowel Movement
date
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
ABDOMINAL DESCRIPTION
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
BOWEL SOUNDS
Item
Darmgeräusche
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
FLATUS
Item
FLATUS
boolean
incontinence
Item
Inkontinenz
boolean
C0021167 (UMLS CUI 2011AA)
48340000 (SNOMED CT 2011_0131)
10021639 (MedDRA 14.1)
GASTRIC SYMPTOMS
Item
GASTRIC SYMPTOMS
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
FEEDING TUBE PRESENT
Item
Ernährung über Sonde
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula (# strength @ # ml's/hour via kangaroo pump)
string
OSTOMY TYPE
Item
OSTOMY TYPE
string
RECTAL BAG PRESENT
Item
RECTAL BAG PRESENT
boolean
Item Group
Urogenitales System
NORMAL BASELINE Genitourinary
Item
Normal Baseline Genitourinary: Voids without pain or hesitation, no suprapubic distention.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Item
Geschlecht
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Code List
Geschlecht
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
CATHETER PRESENT
Item
Katheter
boolean
C0085590 (UMLS CUI 2011AA)
19923001 (SNOMED CT 2011_0131)
CATHETER SIZE
Item
Katheter-Größe
string
C0449963 (UMLS CUI 2011AA)
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)
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
Item Group
Muskuloskeletales System
NORMAL BASELINE Musculoskeletal
Item
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, bones intact, gait steady or age appropriate.
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
PARALYSIS TYPE
Item
PARALYSIS TYPE
string
Item
Hemiplegia Side
string
Code List
Hemiplegia Side
CL Item
left (1)
CL Item
right (2)
FRACTURE(S) LOCATION
Item
FRACTURE(S) LOCATION
string
FINGER DIGITS
Item
FINGER DIGITS
string
TOE DIGITS
Item
TOE DIGITS
string
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
Item Group
Haut
NORMAL BASELINE Skin
Item
Normal Baseline Skin: Warm, pink, dry, elastic, intact, moist mucous membranes.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
TEMPERATURE
Item
Temperatur
float
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN COLOR
Item
SKIN COLOR
string
MOIST
Item
MOIST
boolean
SKIN TURGOR
Item
SKIN TURGOR
string
Item Group
Inzision
Incision #:
Item
Inzision
string
C0184898 (UMLS CUI 2011AA)
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
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
Item Group
Wunde
WOUND #
Item
Wunde
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
MID WOUND#
Item
MID WOUND#
string
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-2)
246267002 (SNOMED CT 2011_0131-2)
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
C0015388 (UMLS CUI 2011AA)
247450001 (SNOMED CT 2011_0131)
MTHU025016 (LOINC Version 232)
Exudate Color
Item
Exudate Color
string
Sensation
Item
Sensation
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
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
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
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
SPECIALTY BEDS
Item
SPECIALTY BEDS
string
Item Group
Nutrition
Current Diet
Item
Diät
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
NPO
Item
NPO
boolean
FEEDING TUBE PRESENT
Item
Ernährung über Sonde
boolean
C0041281 (UMLS CUI 2011AA)
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
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
Item Group
intravenöse Therapie
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)
IV FLUIDS
Item
Infusion
string
C1289919 (UMLS CUI 2011AA)
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
Item Group
Patientensicherheit
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
FALL BAND ON
Item
FALL BAND ON
boolean
BED SAFETY
Item
BED SAFETY
string
Item Group
Pediatric Fall Risk Assessment
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
gender
Item
Geschlecht
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Item
Bewusstseinslage
string
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
Code List
Bewusstseinslage
CL Item
Awake/Alert  (0)
CL Item
Drowsy/Medicated for pain/Seizures (1)
CL Item
Lethargic/Confused (2)
Item
Seizures/Previous history of falls
string
Code List
Seizures/Previous history of falls
CL Item
No significant medical history of falls/ (0)
CL Item
No difficulty in ambulation, Generalized weakness/Dizziness/Syncope/ (1)
CL Item
PT or OT Services, Altered mental status/Developmental Delay/ (2)
Item
MEDICATION/EQUIPMENT
string
Code List
MEDICATION/EQUIPMENT
CL Item
No prescribed medication that has been known to alter LOC. No IV or other equipment (IV, Pulse Oximeter) prescribed for the patient (0)
CL Item
Prescribed pain medication (oral), seizure medication (oral), continuous IV therapy requiring infusion device (1)
CL Item
Prescribed IV/IM pain medication, seizure medication/PCA pump, crutches, CR monitor (2)
Item
Verweildauer
string
C0023303 (UMLS CUI 2011AA)
Code List
Verweildauer
CL Item
Admission as inpatient 0-3 Days (0)
CL Item
Admission as inpatient 4-7 Days (1)
CL Item
Admission as inpatient greater than 7 Days (2)
Item
ELIMINATION
string
Code List
ELIMINATION
CL Item
Takes care of elimination needs independently with no assist/Infant in diapers (0)
CL Item
Independent with frequent trips to bathroom (1)
CL Item
Needs assist with toilet (2)
Item
GET UP AND GO TEST: "RISING FROM A CHAIR"
string
Code List
GET UP AND GO TEST: "RISING FROM A CHAIR"
CL Item
Ability to rise in single movement-No loss of balance with steps (0)
CL Item
Pushes up, successful in one attempt (1)
CL Item
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)
FINAL RISK SCORE
Item
FINAL RISK SCORE (Pediatric Fall Risk Assessment)
integer
Item Group
INTERVENTIONS
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
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
Item Group
IMPAIRED MOBILITY RISK
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
Item Group
ALTERED ELIMINATION
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,
Item
Educate patient/support system about drug classification, side effects,
boolean
precautions, toxic symptoms of overdose.
Item
precautions, toxic symptoms of overdose.
boolean
Item Group
Hendrich II Fall Risk Assessment
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
HENDRICH CALCULATION
Item
HENDRICH CALCULATION
string
Item Group
ONN Unit specific
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
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN CONDITION
Item
Hautzustand
string
C1719933 (UMLS CUI 2011AA)
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
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
Item Group
Post Surgical
General Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
Vaginal Packing
Item
Vaginal Packing
string
Equipment/Devices
Item
Equipment/Devices
string
EQUIPMENT/DEVICES
Item
EQUIPMENT/DEVICES
string
Item Group
ADOLESCENT INTERACTION
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)
Item
Allowed contact with peer group.
string
Code List
Allowed contact with peer group.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Item Group
GERIATRIC INTERVENTION (65+)
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)
Item
Encouraged family/S.O.to visit
string
Code List
Encouraged family/S.O.to visit
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Independence promoted.
string
Code List
Independence promoted.
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string

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