ID

28799

Beschreibung

Routine documentation for Age-Related Macular Degeneration. Eye clinic, University Clinic of Muenster.

Stichworte

Versionen (1)
  1. 05.02.18 05.02.18 -
Rechteinhaber

Eye Clinic UKM

Hochgeladen am

5. Februar 2018

DOI

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Lizenz

Creative Commons BY-NC 3.0
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Example 1 Discharge Letter AMD

Englisch

Example 1 Discharge Letter AMD

1 Formulare  
Administrative data
Beschreibung

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Beschreibung

Patient Name

Datentyp

text

Alias
UMLS CUI [1]
C1299487
Patient date of birth
Beschreibung

Patient date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Patient address
Beschreibung

Patient address

Datentyp

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Beschreibung

Visit Date

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Type of care
Beschreibung

Type of care

Datentyp

text

Alias
UMLS CUI [1,1]
C0086388
UMLS CUI [1,2]
C0332307
Reason for patient visit
Beschreibung

Reason for patient visit

Datentyp

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Beschreibung

Attending physician name

Datentyp

text

Alias
UMLS CUI [1]
C2361125
Recipient
Beschreibung

Recipient

Datentyp

text

Alias
UMLS CUI [1]
C1709854
Recipient's address
Beschreibung

Recipient address

Datentyp

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1442065
Diagnosis Right eye
Beschreibung

Diagnosis Right eye

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229089
Present diagnosis
Beschreibung

diagnosis present

Datentyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Past medical history
Beschreibung

past medical history

Datentyp

text

Alias
UMLS CUI [1]
C3661816
Duration past medical history
Beschreibung

Duration past medical history

Datentyp

text

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C3661816
Study Subject Participation Status
Beschreibung

Study Subject Participation Status

Datentyp

text

Alias
UMLS CUI [1]
C2348568
Diagnosis Left eye
Beschreibung

Diagnosis Left eye

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229090
Present diagnosis
Beschreibung

diagnosis present

Datentyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Past medical history
Beschreibung

past medical history

Datentyp

text

Alias
UMLS CUI [1]
C3661816
Duration past medical history
Beschreibung

Duration past medical history

Datentyp

text

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C3661816
Study Subject Participation Status
Beschreibung

Study Subject Participation Status

Datentyp

text

Alias
UMLS CUI [1]
C2348568
Vision
Beschreibung

Vision

Alias
UMLS CUI-1
C0042789
Vision Right eye
Beschreibung

Vision Right eye

Datentyp

text

Alias
UMLS CUI [1,1]
C0042789
UMLS CUI [1,2]
C0229089
Vision Left eye
Beschreibung

Vision Left eye

Datentyp

text

Alias
UMLS CUI [1,1]
C0042789
UMLS CUI [1,2]
C0229090
Intraocular pressure
Beschreibung

Intraocular pressure

Alias
UMLS CUI-1
C0578862
Intraocular pressure Right eye
Beschreibung

Intraocular pressure Right eye

Datentyp

text

Maßeinheiten
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229089
mmHg
Intraocular pressure Left eye
Beschreibung

Intraocular pressure Left eye

Datentyp

text

Maßeinheiten
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229090
mmHg
Slit lamp biomicroscopy Right eye
Beschreibung

Slit lamp biomicroscopy Right eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229089
IOL in Loco?
Beschreibung

Intraocular lens

Datentyp

boolean

Alias
UMLS CUI [1]
C0496743
Anterior segment of eye- Irritation?
Beschreibung

Anterior segment of eye Eye irritation

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003153
UMLS CUI [1,2]
C0235266
Capsulotomy of lens
Beschreibung

Capsulotomy of lens

Datentyp

boolean

Alias
UMLS CUI [1]
C0197674
Slit lamp biomicroscopy Left eye
Beschreibung

Slit lamp biomicroscopy Left eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229090
IOL in Loco?
Beschreibung

Intraocular lens

Datentyp

boolean

Alias
UMLS CUI [1]
C0496743
Anterior segment of eye- Irritation?
Beschreibung

Anterior segment of eye Eye irritation

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003153
UMLS CUI [1,2]
C0235266
Capsulotomy of lens
Beschreibung

Capsulotomy of lens

Datentyp

boolean

Alias
UMLS CUI [1]
C0197674
Ophthalmoscopy Right eye
Beschreibung

Ophthalmoscopy Right eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229089
In Mydriasis ?
Beschreibung

Mydriasis

Datentyp

boolean

Alias
UMLS CUI [1]
C0026961
Optic disc- vital, sharp margin?
Beschreibung

Optic disc finding vital sharp margin

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Optic disc- Confluent drusen
Beschreibung

Optic disc finding- Confluent drusen

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C1720180
Ophthalmoscopy Left eye
Beschreibung

Ophthalmoscopy Left eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229090
In Mydriasis ?
Beschreibung

Mydriasis

Datentyp

boolean

Alias
UMLS CUI [1]
C0026961
Optic disc- vital, sharp margin?
Beschreibung

Optic disc finding vital sharp margin

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Optic disc- Confluent drusen
Beschreibung

Optic disc finding- Confluent drusen

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C1720180
SD- OCT Right eye
Beschreibung

SD- OCT Right eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229089
Foveal depression?
Beschreibung

Foveal depression

Datentyp

boolean

Alias
UMLS CUI [1]
C2013325
Confluent drusen
Beschreibung

Confluent drusen

Datentyp

boolean

Alias
UMLS CUI [1]
C1720180
Eye oedema
Beschreibung

Eye oedema

Datentyp

boolean

Alias
UMLS CUI [1]
C0743680
Central retina area thickness
Beschreibung

Central retina area thickness

Datentyp

text

Alias
UMLS CUI [1,1]
C0459678
UMLS CUI [1,2]
C1280412
SD- OCT Left eye
Beschreibung

SD- OCT Left eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229090
Foveal depression?
Beschreibung

Foveal depression

Datentyp

boolean

Alias
UMLS CUI [1]
C2013325
Confluent drusen
Beschreibung

Confluent drusen

Datentyp

boolean

Alias
UMLS CUI [1]
C1720180
Eye oedema
Beschreibung

Eye oedema

Datentyp

boolean

Alias
UMLS CUI [1]
C0743680
Central retina area thickness
Beschreibung

Central retina area thickness

Datentyp

text

Alias
UMLS CUI [1,1]
C0459678
UMLS CUI [1,2]
C1280412
Autofluorescence
Beschreibung

Autofluorescence

Alias
UMLS CUI-1
C0544711
Oval-shaped hypofluorescence with hyperfluorescent macula Right eye
Beschreibung

Oval-shaped hypofluorescence with hyperfluorescent macula Right eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C4313699
UMLS CUI [1,2]
C0229089
Oval-shaped hypofluorescence with hyperfluorescent macula Left eye
Beschreibung

Oval-shaped hypofluorescence with hyperfluorescent macula Left eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C4313699
UMLS CUI [1,2]
C0229090
Fluorescein Angiography
Beschreibung

Fluorescein Angiography

Alias
UMLS CUI-1
C0016313
Hyperfluorescence with leaking and pooling Right eye
Beschreibung

hyperfluorescence with leaking and pooling Right eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2062011
UMLS CUI [1,2]
C0229089
Hyperfluorescence with leaking and pooling Left eye
Beschreibung

hyperfluorescence with leaking and pooling Left eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2062011
UMLS CUI [1,2]
C0229090
Indocyanine green angiography
Beschreibung

Indocyanine green angiography

Alias
UMLS CUI-1
C0430879
Hot spot Right eye
Beschreibung

Hot spot Right eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2048947
UMLS CUI [1,2]
C0229089
Hot spot Left eye
Beschreibung

Hot spot Left eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2048947
UMLS CUI [1,2]
C0229090
Evaluation and Treatment
Beschreibung

Evaluation and Treatment

Alias
UMLS CUI-1
C0220825
UMLS CUI-3
C0087111
Diagnosis
Beschreibung

Diagnosis

Datentyp

text

Alias
UMLS CUI [1]
C0011900
Therapy
Beschreibung

Therapy

Datentyp

text

Alias
UMLS CUI [1]
C0087111
Date of start of therapy
Beschreibung

Date of start of therapy

Datentyp

date

Alias
UMLS CUI [1]
C3173309
Zum Seitenanfang zurückkehren

Ähnliche Modelle

Example 1 Discharge Letter AMD

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Patient Name
Item
Patient Name
text
C1299487 (UMLS CUI [1])
Patient date of birth
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Patient address
Item
Patient address
text
C0421449 (UMLS CUI [1])
Visit Date
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Item
Type of care
text
C0086388 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Type of care
Code List
Type of care
CL Item
Inpatient (Inpatient)
C0021562 (UMLS CUI-1)
(Comment:en)
CL Item
Outpatients (Outpatients)
C0029921 (UMLS CUI-1)
(Comment:en)
Item
Reason for patient visit
text
C1704447 (UMLS CUI [1])
Reason for patient visit
Code List
Reason for patient visit
CL Item
First consultation (First consultation)
C3826021 (UMLS CUI-1)
(Comment:en)
CL Item
Follow- up (Follow- up)
C0589121 (UMLS CUI-1)
(Comment:en)
Attending physician name
Item
Attending physician name
text
C2361125 (UMLS CUI [1])
Recipient
Item
Recipient
text
C1709854 (UMLS CUI [1])
Recipient address
Item
Recipient's address
text
C1709854 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Item Group
Diagnosis Right eye
C0011900 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Item
Present diagnosis
text
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
diagnosis present
Code List
Present diagnosis
CL Item
Age-Related Macular Degeneration (occult CNV) (Age-Related Macular Degeneration)
C0242383 (UMLS CUI-1)
(Comment:en)
Item
Past medical history
text
C3661816 (UMLS CUI [1])
past medical history
Code List
Past medical history
CL Item
YAG Lasers capsulotomy (YAG Lasers capsulotomy)
C0587723 (UMLS CUI-1)
C0197674 (UMLS CUI-2)
(Comment:en)
CL Item
Cataract surgery (Cataract surgery)
C2939459 (UMLS CUI-1)
(Comment:en)
Duration past medical history
Item
Duration past medical history
text
C0449238 (UMLS CUI [1,1])
C3661816 (UMLS CUI [1,2])
Study Subject Participation Status
Item
Study Subject Participation Status
text
C2348568 (UMLS CUI [1])
Item Group
Diagnosis Left eye
C0011900 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Item
Present diagnosis
text
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
diagnosis present
Code List
Present diagnosis
CL Item
Age-Related Macular Degeneration (dry) (Age-Related Macular Degeneration)
C0242383 (UMLS CUI-1)
(Comment:en)
Item
Past medical history
text
C3661816 (UMLS CUI [1])
past medical history
Code List
Past medical history
CL Item
Cataract surgery (Cataract surgery)
C2939459 (UMLS CUI-1)
(Comment:en)
Duration past medical history
Item
Duration past medical history
text
C0449238 (UMLS CUI [1,1])
C3661816 (UMLS CUI [1,2])
Study Subject Participation Status
Item
Study Subject Participation Status
text
C2348568 (UMLS CUI [1])
Item Group
Vision
C0042789 (UMLS CUI-1)
Vision Right eye
Item
Vision Right eye
text
C0042789 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Vision Left eye
Item
Vision Left eye
text
C0042789 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Intraocular pressure
C0578862 (UMLS CUI-1)
Intraocular pressure Right eye
Item
Intraocular pressure Right eye
text
C0578862 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Intraocular pressure Left eye
Item
Intraocular pressure Left eye
text
C0578862 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Slit lamp biomicroscopy Right eye
C0419360 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Intraocular lens
Item
IOL in Loco?
boolean
C0496743 (UMLS CUI [1])
Anterior segment of eye Eye irritation
Item
Anterior segment of eye- Irritation?
boolean
C0003153 (UMLS CUI [1,1])
C0235266 (UMLS CUI [1,2])
Capsulotomy of lens
Item
Capsulotomy of lens
boolean
C0197674 (UMLS CUI [1])
Item Group
Slit lamp biomicroscopy Left eye
C0419360 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Intraocular lens
Item
IOL in Loco?
boolean
C0496743 (UMLS CUI [1])
Anterior segment of eye Eye irritation
Item
Anterior segment of eye- Irritation?
boolean
C0003153 (UMLS CUI [1,1])
C0235266 (UMLS CUI [1,2])
Capsulotomy of lens
Item
Capsulotomy of lens
boolean
C0197674 (UMLS CUI [1])
Item Group
Ophthalmoscopy Right eye
C0029090 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Mydriasis
Item
In Mydriasis ?
boolean
C0026961 (UMLS CUI [1])
Optic disc finding vital sharp margin
Item
Optic disc- vital, sharp margin?
boolean
C0423451 (UMLS CUI [1,1])
C0442732 (UMLS CUI [1,2])
C2963144 (UMLS CUI [1,3])
Optic disc finding- Confluent drusen
Item
Optic disc- Confluent drusen
boolean
C0423451 (UMLS CUI [1,1])
C1720180 (UMLS CUI [1,2])
Item Group
Ophthalmoscopy Left eye
C0029090 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Mydriasis
Item
In Mydriasis ?
boolean
C0026961 (UMLS CUI [1])
Optic disc finding vital sharp margin
Item
Optic disc- vital, sharp margin?
boolean
C0423451 (UMLS CUI [1,1])
C0442732 (UMLS CUI [1,2])
C2963144 (UMLS CUI [1,3])
Optic disc finding- Confluent drusen
Item
Optic disc- Confluent drusen
boolean
C0423451 (UMLS CUI [1,1])
C1720180 (UMLS CUI [1,2])
Item Group
SD- OCT Right eye
C3876157 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Foveal depression
Item
Foveal depression?
boolean
C2013325 (UMLS CUI [1])
Confluent drusen
Item
Confluent drusen
boolean
C1720180 (UMLS CUI [1])
Eye oedema
Item
Eye oedema
boolean
C0743680 (UMLS CUI [1])
Central retina area thickness
Item
Central retina area thickness
text
C0459678 (UMLS CUI [1,1])
C1280412 (UMLS CUI [1,2])
Item Group
SD- OCT Left eye
C3876157 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Foveal depression
Item
Foveal depression?
boolean
C2013325 (UMLS CUI [1])
Confluent drusen
Item
Confluent drusen
boolean
C1720180 (UMLS CUI [1])
Eye oedema
Item
Eye oedema
boolean
C0743680 (UMLS CUI [1])
Central retina area thickness
Item
Central retina area thickness
text
C0459678 (UMLS CUI [1,1])
C1280412 (UMLS CUI [1,2])
Item Group
Autofluorescence
C0544711 (UMLS CUI-1)
Oval-shaped hypofluorescence with hyperfluorescent macula Right eye
Item
Oval-shaped hypofluorescence with hyperfluorescent macula Right eye
boolean
C4313699 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Oval-shaped hypofluorescence with hyperfluorescent macula Left eye
Item
Oval-shaped hypofluorescence with hyperfluorescent macula Left eye
boolean
C4313699 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Fluorescein Angiography
C0016313 (UMLS CUI-1)
hyperfluorescence with leaking and pooling Right eye
Item
Hyperfluorescence with leaking and pooling Right eye
boolean
C2062011 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
hyperfluorescence with leaking and pooling Left eye
Item
Hyperfluorescence with leaking and pooling Left eye
boolean
C2062011 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Indocyanine green angiography
C0430879 (UMLS CUI-1)
Hot spot Right eye
Item
Hot spot Right eye
boolean
C2048947 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Hot spot Left eye
Item
Hot spot Left eye
boolean
C2048947 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Evaluation and Treatment
C0220825 (UMLS CUI-1)
C0087111 (UMLS CUI-3)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Item
Therapy
text
C0087111 (UMLS CUI [1])
Therapy
Code List
Therapy
CL Item
Intravitreal Injections Lucentis (Intravitreal Injections Lucentis)
C1554888 (UMLS CUI-1)
C3234800 (UMLS CUI-2)
(Comment:en)
Date of start of therapy
Item
Date of start of therapy
date
C3173309 (UMLS CUI [1])
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