ID

28802

Beskrivning

Routine documentation for Diabetic Retinopathy. Eye clinic, University Clinic of Muenster.

Nyckelord

Versioner (2)
  1. 2018-02-05 2018-02-05 -
  2. 2021-09-17 2021-09-17 -
Rättsinnehavare

Eye Clinic UKM

Uppladdad den

5 februari 2018

DOI

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Creative Commons BY-NC 3.0
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Example 1 Discharge Letter Diabetic Retinopathy

Engelsk

Example 1

2 Formulär  
  1. StudyEvent: ODM
    1. Example 1
    2. Example 2
Administrative data
Beskrivning

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Beskrivning

Patient Name

Datatyp

text

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

Patient date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Patient address
Beskrivning

Patient address

Datatyp

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Beskrivning

Visit Date

Datatyp

date

Alias
UMLS CUI [1]
C1320303
Type of care
Beskrivning

Type of care

Datatyp

text

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

Reason for patient visit

Datatyp

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Beskrivning

Attending physician name

Datatyp

text

Alias
UMLS CUI [1]
C2361125
Recipient
Beskrivning

Recipient

Datatyp

text

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

Recipient address

Datatyp

text

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

Diagnosis Right eye

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

diagnosis present

Datatyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Diagnosis Left eye
Beskrivning

Diagnosis Left eye

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

diagnosis present

Datatyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Date of procedure
Beskrivning

date of procedure

Datatyp

date

Alias
UMLS CUI [1]
C2584899
Vision
Beskrivning

Vision

Alias
UMLS CUI-1
C0042789
Vision Right eye
Beskrivning

Vision Right eye

Datatyp

text

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

Vision Left eye

Datatyp

text

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

Intraocular pressure

Alias
UMLS CUI-1
C0578862
Intraocular pressure Right eye
Beskrivning

Intraocular pressure Right eye

Datatyp

text

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

Intraocular pressure Left eye

Datatyp

text

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

Slit lamp biomicroscopy Right eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229089
Anterior segment of eye- Irritation?
Beskrivning

Anterior segment of eye Eye irritation

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0003153
UMLS CUI [1,2]
C0235266
Cataracta corticonuclearis
Beskrivning

Cataract

Datatyp

boolean

Alias
UMLS CUI [1]
C0086543
Rubeosis
Beskrivning

Rubeosis

Datatyp

boolean

Alias
UMLS CUI [1]
C0154916
Pupil
Beskrivning

Pupil

Datatyp

text

Alias
UMLS CUI [1]
C0034121
Slit lamp biomicroscopy Left eye
Beskrivning

Slit lamp biomicroscopy Left eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229090
Deposition of cornea "Eisenlinie"
Beskrivning

deposition; cornea

Datatyp

boolean

Alias
UMLS CUI [1]
C1386913
Ophthalmoscopy Right eye
Beskrivning

Ophthalmoscopy Right eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229089
Optic disc- vital, sharp margin?
Beskrivning

Optic disc finding vital sharp margin

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Macula normal
Beskrivning

Macula

Datatyp

boolean

Alias
UMLS CUI [1]
C0450295
Diabetic retinal microaneurysm
Beskrivning

Diabetic retinal microaneurysm

Datatyp

boolean

Alias
UMLS CUI [1]
C0271064
Retinal Hemorrhage
Beskrivning

Retinal Hemorrhage

Datatyp

boolean

Alias
UMLS CUI [1]
C0035317
Ophthalmoscopy Left eye
Beskrivning

Ophthalmoscopy Left eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229090
Optic disc- vital, sharp margin?
Beskrivning

Optic disc finding vital sharp margin

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Macula
Beskrivning

Macula

Datatyp

text

Alias
UMLS CUI [1]
C0450295
Diabetic retinal microaneurysm
Beskrivning

Diabetic retinal microaneurysm

Datatyp

boolean

Alias
UMLS CUI [1]
C0271064
Retinal Hemorrhage
Beskrivning

Retinal Hemorrhage

Datatyp

boolean

Alias
UMLS CUI [1]
C0035317
SD- OCT Right eye
Beskrivning

SD- OCT Right eye

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

Foveal depression

Datatyp

boolean

Alias
UMLS CUI [1]
C2013325
Foveal thickness right
Beskrivning

Foveal thickness right

Datatyp

boolean

Alias
UMLS CUI [1]
C4069287
SD- OCT Left eye
Beskrivning

SD- OCT Left eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229090
Diabetic retinal microaneurysm
Beskrivning

Diabetic retinal microaneurysm

Datatyp

boolean

Alias
UMLS CUI [1]
C0271064
Macula edema
Beskrivning

Macula edema

Datatyp

boolean

Alias
UMLS CUI [1]
C1403471
Macular exudation
Beskrivning

Macular exudation

Datatyp

boolean

Alias
UMLS CUI [1]
C4072984
Atrophic retina
Beskrivning

Atrophic retina

Datatyp

boolean

Alias
UMLS CUI [1]
C0521694
Fluorescein Angiography
Beskrivning

Fluorescein Angiography

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

hyperfluorescence with leaking and pooling Right eye

Datatyp

boolean

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

hyperfluorescence with leaking and pooling Left eye

Datatyp

boolean

Alias
UMLS CUI [1,1]
C2062011
UMLS CUI [1,2]
C0229090
Intraretinal microvascular abnormality IRMA
Beskrivning

Intraretinal microvascular abnormality

Datatyp

boolean

Alias
UMLS CUI [1]
C3714733
Retinal Neovascularization
Beskrivning

Retinal Neovascularization

Datatyp

boolean

Alias
UMLS CUI [1]
C0035320
Evaluation and Treatment
Beskrivning

Evaluation and Treatment

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

Diagnosis

Datatyp

text

Alias
UMLS CUI [1]
C0011900
Therapy
Beskrivning

Therapy

Datatyp

text

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

Date of start of therapy

Datatyp

date

Alias
UMLS CUI [1]
C3173309
Date of procedure
Beskrivning

Date of procedure

Datatyp

date

Alias
UMLS CUI [1]
C2584899
Next Visit Date
Beskrivning

Next visit date

Datatyp

date

Alias
UMLS CUI [1]
C2735342
Tillbaka till toppen

Similar models

Example 1

2 Formulär
  1. StudyEvent: ODM
    1. Example 1
    2. Example 2
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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
Diabetic Retinopathy (Diabetic Retinopathy)
C0011884 (UMLS CUI-1)
(Comment:en)
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
Intravitreal Injections Lucentis (Intravitreal Injections Lucentis)
C1554888 (UMLS CUI-1)
C3234800 (UMLS CUI-2)
(Comment:en)
CL Item
Diabetic Macula Edema ( Macula Edema Diabetic)
C2092759 (UMLS CUI-1)
(Comment:en)
date of procedure
Item
Date of procedure
date
C2584899 (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)
Anterior segment of eye Eye irritation
Item
Anterior segment of eye- Irritation?
boolean
C0003153 (UMLS CUI [1,1])
C0235266 (UMLS CUI [1,2])
Cataract
Item
Cataracta corticonuclearis
boolean
C0086543 (UMLS CUI [1])
Rubeosis
Item
Rubeosis
boolean
C0154916 (UMLS CUI [1])
Item
Pupil
text
C0034121 (UMLS CUI [1])
Optic Disk
Code List
Pupil
CL Item
Round (Round)
C0332490 (UMLS CUI-1)
(Comment:en)
CL Item
Reacts (Reacts)
C0423300 (UMLS CUI-1)
(Comment:en)
Item Group
Slit lamp biomicroscopy Left eye
C0419360 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
deposition; cornea
Item
Deposition of cornea "Eisenlinie"
boolean
C1386913 (UMLS CUI [1])
Item Group
Ophthalmoscopy Right eye
C0029090 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
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])
Macula
Item
Macula normal
boolean
C0450295 (UMLS CUI [1])
Diabetic retinal microaneurysm
Item
Diabetic retinal microaneurysm
boolean
C0271064 (UMLS CUI [1])
Retinal Hemorrhage
Item
Retinal Hemorrhage
boolean
C0035317 (UMLS CUI [1])
Item Group
Ophthalmoscopy Left eye
C0029090 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
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])
Item
Macula
text
C0450295 (UMLS CUI [1])
Macula
Code List
Macula
CL Item
Macular exudation (Macular exudation)
C4072984 (UMLS CUI-1)
(Comment:en)
CL Item
macula edema (Macula edema)
C1403471 (UMLS CUI-1)
(Comment:en)
Diabetic retinal microaneurysm
Item
Diabetic retinal microaneurysm
boolean
C0271064 (UMLS CUI [1])
Retinal Hemorrhage
Item
Retinal Hemorrhage
boolean
C0035317 (UMLS CUI [1])
Item Group
SD- OCT Right eye
C3876157 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Foveal depression
Item
Foveal depression?
boolean
C2013325 (UMLS CUI [1])
Foveal thickness right
Item
Foveal thickness right
boolean
C4069287 (UMLS CUI [1])
Item Group
SD- OCT Left eye
C3876157 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Diabetic retinal microaneurysm
Item
Diabetic retinal microaneurysm
boolean
C0271064 (UMLS CUI [1])
Macula edema
Item
Macula edema
boolean
C1403471 (UMLS CUI [1])
Macular exudation
Item
Macular exudation
boolean
C4072984 (UMLS CUI [1])
Atrophic retina
Item
Atrophic retina
boolean
C0521694 (UMLS CUI [1])
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])
Intraretinal microvascular abnormality
Item
Intraretinal microvascular abnormality IRMA
boolean
C3714733 (UMLS CUI [1])
Retinal Neovascularization
Item
Retinal Neovascularization
boolean
C0035320 (UMLS CUI [1])
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)
CL Item
OCT (Follow- up) (OCT (Follow- up))
C0920367 (UMLS CUI-1)
(Comment:en)
Date of start of therapy
Item
Date of start of therapy
date
C3173309 (UMLS CUI [1])
Date of procedure
Item
Date of procedure
date
C2584899 (UMLS CUI [1])
Next visit date
Item
Next Visit Date
date
C2735342 (UMLS CUI [1])
Tillbaka till toppen 

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