ID

28803

Beschrijving

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

Trefwoorden

Versies (1)
  1. 05-02-18 05-02-18 -
Houder van rechten

Eye Clinic UKM

Geüploaded op

5 februari 2018

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Example 2 Discharge Letter Diabetic Retinopathy

Engels

Example 2

2 Formulieren  
  1. StudyEvent: ODM
    1. Example 2
    2. Example 2
Administrative data
Beschrijving

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Beschrijving

Patient Name

Datatype

text

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

Patient date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Patient address
Beschrijving

Patient address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Beschrijving

Visit Date

Datatype

date

Alias
UMLS CUI [1]
C1320303
Type of care
Beschrijving

Type of care

Datatype

text

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

Reason for patient visit

Datatype

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Beschrijving

Attending physician name

Datatype

text

Alias
UMLS CUI [1]
C2361125
Recipient
Beschrijving

Recipient

Datatype

text

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

Recipient address

Datatype

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1442065
Diagnosis Both eyes
Beschrijving

Diagnosis Both eyes

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229118
Present diagnosis
Beschrijving

diagnosis present

Datatype

text

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

Diagnosis Left eye

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

diagnosis present

Datatype

text

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

date of procedure

Datatype

date

Alias
UMLS CUI [1]
C2584899
Therapeutic procedures
Beschrijving

Therapeutic procedures

Alias
UMLS CUI-1
C0087111
Eye
Beschrijving

Eye

Datatype

text

Alias
UMLS CUI [1]
C0015392
Laser coagulation burn to retina
Beschrijving

Laser coagulation burn to retina

Datatype

boolean

Alias
UMLS CUI [1]
C0339486
Destruction of lesion of choroid by laser coagulation
Beschrijving

Destruction of lesion of choroid by laser coagulation

Datatype

boolean

Alias
UMLS CUI [1]
C0395607
Vision
Beschrijving

Vision

Alias
UMLS CUI-1
C0042789
Vision Right eye
Beschrijving

Vision Right eye

Datatype

text

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

Vision Left eye

Datatype

text

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

Intraocular pressure

Alias
UMLS CUI-1
C0578862
Intraocular pressure Right eye
Beschrijving

Intraocular pressure Right eye

Datatype

text

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

Intraocular pressure Left eye

Datatype

text

Maateenheden
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229090
mmHg
Slit lamp biomicroscopy Both eyes
Beschrijving

Slit lamp biomicroscopy Both eyes

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229118
Cataract
Beschrijving

Cataract

Datatype

boolean

Alias
UMLS CUI [1]
C0086543
Ophthalmoscopy Right eye
Beschrijving

Ophthalmoscopy Right eye

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

Optic disc finding vital sharp margin

Datatype

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Retinal Hemorrhage
Beschrijving

Retinal Hemorrhage

Datatype

boolean

Alias
UMLS CUI [1]
C0035317
Retinal exudation
Beschrijving

Retinal exudation

Datatype

boolean

Alias
UMLS CUI [1]
C4068857
Papilledema
Beschrijving

Papilledema

Datatype

boolean

Alias
UMLS CUI [1]
C0030353
Ophthalmoscopy Left eye
Beschrijving

Ophthalmoscopy Left eye

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

Optic disc finding vital sharp margin

Datatype

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Retinal Hemorrhage
Beschrijving

Retinal Hemorrhage

Datatype

boolean

Alias
UMLS CUI [1]
C0035317
Retinal exudation
Beschrijving

Retinal exudation

Datatype

boolean

Alias
UMLS CUI [1]
C4068857
Retinal fovea Edema
Beschrijving

Retinal fovea Edema

Datatype

boolean

Alias
UMLS CUI [1,1]
C0877659
UMLS CUI [1,2]
C0013604
OCT Macula
Beschrijving

OCT Macula

Alias
UMLS CUI-1
C2013322
UMLS CUI-2
C0450295
Eye
Beschrijving

Eye

Datatype

text

Alias
UMLS CUI [1]
C0015392
Retinal edema
Beschrijving

Retinal edema

Datatype

boolean

Alias
UMLS CUI [1]
C0242420
Fluorescein Angiography
Beschrijving

Fluorescein Angiography

Alias
UMLS CUI-1
C0016313
fluorescein angiography hyperfluorescence Right eye
Beschrijving

fluorescein angiography: hyperfluorescence Right eye

Datatype

boolean

Alias
UMLS CUI [1,1]
C2061992
UMLS CUI [1,2]
C0229089
Hyperfluorescence with leaking and pooling Left eye
Beschrijving

hyperfluorescence with leaking and pooling Left eye

Datatype

boolean

Alias
UMLS CUI [1,1]
C2062011
UMLS CUI [1,2]
C0229090
Evaluation and Treatment
Beschrijving

Evaluation and Treatment

Alias
UMLS CUI-1
C0220825
UMLS CUI-2
C0087111
Diagnosis
Beschrijving

Diagnosis

Datatype

text

Alias
UMLS CUI [1]
C0011900
Laser therapy for retinal lesion
Beschrijving

Laser therapy for retinal lesion

Datatype

text

Alias
UMLS CUI [1]
C0438670
Further therapies
Beschrijving

Therapy

Datatype

text

Alias
UMLS CUI [1]
C0087111
Next Visit Date
Beschrijving

Next visit date

Datatype

date

Alias
UMLS CUI [1]
C2735342
Terug naar het begin van de pagina

Similar models

Example 2

2 Formulieren
  1. StudyEvent: ODM
    1. Example 2
    2. Example 2
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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 Both eyes
C0011900 (UMLS CUI-1)
C0229118 (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
Nonproliferative diabetic retinopathy (Nonproliferative diabetic retinopathy)
C0004606 (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
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
Therapeutic procedures
C0087111 (UMLS CUI-1)
Item
Eye
text
C0015392 (UMLS CUI [1])
Eye
Code List
Eye
CL Item
Right Eye (Right Eye)
C0229089 (UMLS CUI-1)
(Comment:en)
CL Item
Left Eye (Left Eye)
C0229090 (UMLS CUI-1)
(Comment:en)
Laser coagulation burn to retina
Item
Laser coagulation burn to retina
boolean
C0339486 (UMLS CUI [1])
Destruction of lesion of choroid by laser coagulation
Item
Destruction of lesion of choroid by laser coagulation
boolean
C0395607 (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 Both eyes
C0419360 (UMLS CUI-1)
C0229118 (UMLS CUI-2)
Cataract
Item
Cataract
boolean
C0086543 (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])
Retinal Hemorrhage
Item
Retinal Hemorrhage
boolean
C0035317 (UMLS CUI [1])
Retinal exudation
Item
Retinal exudation
boolean
C4068857 (UMLS CUI [1])
Papilledema
Item
Papilledema
boolean
C0030353 (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])
Retinal Hemorrhage
Item
Retinal Hemorrhage
boolean
C0035317 (UMLS CUI [1])
Retinal exudation
Item
Retinal exudation
boolean
C4068857 (UMLS CUI [1])
Retinal fovea Edema
Item
Retinal fovea Edema
boolean
C0877659 (UMLS CUI [1,1])
C0013604 (UMLS CUI [1,2])
Item Group
OCT Macula
C2013322 (UMLS CUI-1)
C0450295 (UMLS CUI-2)
Item
Eye
text
C0015392 (UMLS CUI [1])
Eye
Code List
Eye
CL Item
Right Eye (Right Eye)
C0229089 (UMLS CUI-1)
(Comment:en)
CL Item
Left Eye (Left Eye)
C0229090 (UMLS CUI-1)
(Comment:en)
Retinal edema
Item
Retinal edema
boolean
C0242420 (UMLS CUI [1])
Item Group
Fluorescein Angiography
C0016313 (UMLS CUI-1)
fluorescein angiography: hyperfluorescence Right eye
Item
fluorescein angiography hyperfluorescence Right eye
boolean
C2061992 (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
Evaluation and Treatment
C0220825 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Item
Laser therapy for retinal lesion
text
C0438670 (UMLS CUI [1])
Therapy
Code List
Laser therapy for retinal lesion
CL Item
Argon laser (Argon laser)
C0392247 (UMLS CUI-1)
(Comment:en)
Item
Further therapies
text
C0087111 (UMLS CUI [1])
Therapy
Code List
Further therapies
CL Item
Blood glucose control (Blood glucose control)
C1337303 (UMLS CUI-1)
(Comment:en)
CL Item
Blood pressure control (Blood pressure control)
C1753303 (UMLS CUI-1)
(Comment:en)
Next visit date
Item
Next Visit Date
date
C2735342 (UMLS CUI [1])
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial